99120008 47,?- Qo5�
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBE
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1B0 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
Q 76 C Ji Zj U r LJ RESIDENTIAL COMMERCIAL OTHER
OWNER'S �k HAZARDOUS FIRE AREA
'. `1 L'r--� ,^�C YES E] If yes-I understand that a Class A
W
NAME 146St Q� , 1lJ` J roof assembly is required.
NO EJInitial I.C.B.O.R
ADDRESS— q I� `ZZJ -c EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS Z
CONTRACTOR'S _ � "��,
NAME � Z
9<,!LA L� es y CI16(=(;fSys4z TO BE REMOVED_ TOBERETAINED
ADDRESS //--77^-'77 �/ D TYPE OF ROOF COVERING
CITY a zIP ba—�—I Ll(t��S Racal �S f Z EXISTING
.PHONE___ q e"") rm "I -7-7 ! BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGL ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAK ❑
7000)of Division 3 of the Business and Professions Code,and my license is in lull force antl
effect.
Gt'3`r C'�O WOOD SHINGLES ❑
License Class Up.Number � �
p �, otSl=wt. OTHER(SPECIFY �' ❑
Date Contractor
OWNER-BUILDER DECLARATION IPROPOSED
hereby affirm that am exempt from the Contractor's License Law for the following reason. Illllf-'
(Sec.construct,
It r,improve,
and Professions Code: Any city or county which requires a permit to I JJ
applicant
suimprove,demto file signed star any tement that
prior toits issuance,alsore quires the BUILT-UP ROOF / y
applicant forsuch permit to file asignedstatement nci g it licensed pursuant to the provisions
of the Contractor's License Law)or that S(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 SHING ES ❑
exemption.Any violation of Section `vy
hundred
by any applicant for a permit subjects the applicant to
o civil penalty of not more than live huntlred employees
dollars(h wag): WOOD SHAKES
E]1, adt r of the property,or tmy eemployeeswith wages astheir sole compensation,will s.
She work,antl She structure is not Intended or offered for sale n owner
Business and Profen
improvesrra in. he Contractor's License Law does s noonapply through
his Own employers,pho rovide ds or WOOD SHINGLES ❑
improves thereon,and who doessuchwork himself or through his own employees,provided that
such improvements are not intended th offered for sale. ill however,the en of pr or improvement
n tsold build or
prove for purpose
s the ownor-bulltler will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7049,Business and Professions Code:The Contractor's License Law 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 a contractor(s)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
I am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to setf-insure for Worker's Compensation, '7 �� 5 Building
as provided for by Section 3700 of the Labor Code,for the performance at the work for which this 1 Z- (,
permit is issued. Seismic
Compensation
have and will maintain Worker's Compensation Insurance,as required by Section 3700 of V7 ^0 S —��
the Labor Code,for the performance of She work for which this permit is issued.My Workers
Compensation Insurance carrier and Policy number are: r/,�,� ae�� �LI Total
Carder Q 1 4 Policy No.K1H L rCZ_7— ) PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXE TION FROM WORKERS'
COMPENSATI INSURANCE N.C.Q
(This section need not be completed if the permit is for one hundred dollars 00)or less.) 2- 4
certify that in the performance of the work for whim this mil is is eQ shall not employ l
any person in any manner so as to become sublect to the ars Co pen ion Laws of call. All roofs shall be inspected prior to any roofing material being
fornia. installed. It a roof is installed without first obtaining an
Date-_� Applicant i spection.I agree t ve all new materials for inspection.
NOTICE T AP 1CANT: If,after making this C icate of Exem I n,you should become p 'cant unders In s an will comply with all non point
subject to In orkers'Compensation provisions of the Labor Code, must forthwith comply
with such provisions or this permit shall be doomed revoked, sour regulation .
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 stale laws relating to building construction,and All r0 COV rings t be Suer.
hereby authorize representatives of this city 10 enter upon the above-mentionetl property for im
spedion purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may in any way accrue against said City In consequence NATURE OF APPLICANT DATE
of the granting of this permit.
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY