R 5198 PERMIT R_ 519 8
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 150 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LASTCALLED INSPECTION.
. BUILDING ADDRESS 11196 9'�- oyY e w 00d a t
9 UI RESIDENTIAL COMMERCIAL OTHER
OWNER'S r 1 HAZARDOUS FIRE AREA
NAME L• i n Afd I nl n nT(/J 0 O k NO ❑ If
assembly s requirenderstand d.
a Class A
1 ❑ Initial I.C.B.O.e
ADDRESS /9�9`� 01 Je i'V o o O/ g-7 � EXISTING ROOF COVERING
�G t�
PHONE V NUMBER OF EXISTING COVERINGS
CONTRACTOR'S ) ^T �/
NAME Qn nT' (wan C 0 • n 1 YI 'r TO BE REMOVED TO BE RETAINED t+
i ADDRESS / T/� /ll./1e ST Save Carlos g+. TYPE OF ROOF COVERING
s CITY&ZIP
SaJv) <TOS e- Ctl EXISTING LAS
PHONE ��n/�-7Z � S/9 BUILT-UP ROOF
LICENSE
NUMBER 6S0bu1:7� ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter S(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Coda,and my license Is In full force and
effect.
C 39 ( o6�a WOOD SHINGLES El
License Class U Number
Dale 9-30 -'76 Contractor R nOO� OTHER(SPECIFY) ❑
to
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that am exempt from om the Contractor's License Law for the following reason.
(Sae.hereby
, Irm that
I and xempt fromons Code: Any airy or county which requires a permit n.
construct,attar,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF
applicant for such permit to filo a signed statement that he Is licensed pursuant to the provisions
of the Contractors License LawChapter 5(commencing with Section 7000)of Division 3 of the
. Business and Professions Code or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑,'
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than live hundred dollars($500).):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7004,Business and Proles- rr��--,,
alone Code:The Contractor's License Lew does not apply to an owner of property who builds or WOOD SHINGLES SE ILS O 1996
Improves thereon,and who does such work himself orthrough his own employees,provided that
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) :'lit 1�❑•' 't
not build of Improve for purpose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects - /^
with am exempt andlicensedSe pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS. 3 n
❑I em exempt under sec. ,B 8 P.C.for this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: —Q /X�^O
❑ have and will maintain a of the Lab of Consent to self-Insure a for Worker's Compensation,which
this 7- 30 v ON/ OY Buildin
as provided im by Section 3700 0l the Labor Coon,for the performance of Wthe work for which this
per Itl Seismic
ave and
will maithe performance
Workers f th1,work on Insurance,as required by Section Workers 0l
the Labor Code,for the performance of ihs work for which this permit Is Issued,My Workers /
Compensation Insurance carrier and Policy number are: Total 7
Carrier S+92tI F/wy1d Policy Ni95 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) 3
I certify that In the performance of the work for which this permit le Issued,I shall.not employ
r any person In any manner so as to become subject to the Workern'Compensation Laws of Call- All roofs shall be inspected prior to any roofing material being
fornla. installed. If a roof is installed without first obtaining an
Date -/ ' 0 %Applicant Iff ldtz2 ,!�_ inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,atter making this Certificate of Exemption,you should become Applicant understands and will comply subject to the Workers'Compensation provisions of the Labor Cone,you must forthwith comply pP ply with all non point
with such provisions or this permit shell be deemed revoked. source regulations.
I certify that I have read this application and state that the above Information Is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,endAll roof Coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
specdon purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertinoa4alnal liabilities,
jud menta,Croats and expenses which may In any way accrue against said City n consequence
• ofKgranting ofthis permit. SIGNATURE OF APPLICANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY