R 48059
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PERMIT
4.8 0 5
APPLICATION FOR CITY of CUPERTINO NUMBERR_
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
r
O I A
RESIDENTIAL COMMERCIAL OTHER
OWNER', ,yA� ,,.o V I q� /t
HAZARDOUS FIRE AREA
C �
VESeEes I understand that. Class A
NAME ✓�aNYI Z'LC
s
f assembly is required.
NCO Initia I.C.B.O. M
Is L C dd' Q
7
EXISTING ROOF COVERING
ADDRESS O S L �—
PHONE D
NUMBER OF EXISTING COVERINGS
TO BE REMOVED TO BE RETAINED
CONTRACJj S rS,
NAME f
ADDREss
I'I'v
7YPE OF ROOF COVERING
CITV BZIP y
._ 20 9BUILT-UP
PHONE
❑
ROOFLICENSE
A
NUMBER
I
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter B (commencing with Section
WOOD SHAKES
7000)of DMaron 3 of the Business and Professions Code, and my license is In full force and
effect.
ny �
Class - ✓ Lic.Numbar
WOOD SHINGLES El
OTHER (SPECIFY) d ❑
Data Coni ecmr
OWNER -BUILDER DECLARATION
PROPOSED APR X
1 hereby affirm that I am exempt from the Contractor's License Law for the kllowing reason.
(Sec. 7031.5, Business and Professions Coda: Any city or county which requires a permit to
9 ��
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construct, alter, Improve ,demolish, or repair any structure, prior to Its Issuance, also requires the
applicant for such to file a signed steams het he Is licensed to the
BUILT-UP ROOF -160
V%
U
permit pursuant provisions
of the Contractor's License Law (Chapter g (cam with Section 7000) of Division 3 of the
Ur".tyf
Business and Professions Code) or that aJCaxe refrom and the basis for the alleged
ASPHALT SHINGLES fAL❑
exemption. Any violation of Section 7031.x5, any ap Nor a permit subjects the applicant to
a civil ponelty of not or than five hundretl alters o).
❑l, as owner of the property, )/ainpl s II gas as their sole compensation, will do
the work, entl the structure Is Intantletl r sale (Sec. 7044, Business and Profes-
WOOD SHAKES ❑
sions Code: The Contractor's Ipdngq L t apply to an owner of property who builds or
Improves thereon, end who tlo 1� I sit or through his own °mpioyeee, provided that
WOOD SHINGLES ❑
such Improvements are not Int ad o a for sale. If, however, the building or Improvement
is sold within one year of comp at to in..oWner-bullder will have the burden of proving that he did
not bulla or Improve for
OTHER (SPECIFY)
purpose m
❑ I, ec owner of the property, am exclusivelyProfessionsseL to construct
and ProrImprov Cotle:
iocontracting with licensers License Law not
the protect (Sac. 7044, Businproperty
PROVIDE LC.B.O. REPORT NO.
h or Improves thereon, end who contracts for such projects
on, and projects
apply to c ntowner) property who pursuant
with a contractors) pursuant to the Contractor's ucenae Lew.
under
I em exempt unser Sec. ,B 6 P. C. for this reason
a
PROVIDE MFGR. INSTALLATION SPECS.
Owner Dela
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 Coneam to self -Insure for Workers Compensation,
Building
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit is haveand Insurance, as required by Section 0l
❑ have entl will the
Worker's Compensation the
Labor Cade, for the of the for Is
I
I I 71 ` A�
I J
Seismic
.the pert
performance workfor
work which this permit Issued, My Worker's
Workers
Compense nsu nce cair«Pmiter are:
f
Total
Carnal - 5 7
PERMIT AUTHORIZATION
DATE
PoucyZ
CERTIFICATE OF EXEMPTION FROM WORKERS'
Is
J�y
COMPENSATION INSURANCE N.C.0
(This section need not be completed if the permit is for one hundred dollarsfS100) or less.)
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I certify that in the performance of the work for which this permit Is Issued, 1 shell not employ
All roofs sTialrbe inspected priorlo any r fing material being
any person In any manner so as to became subject to the Workers' Compensation Laws of Cell-
fornia.
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installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
Applicant understands and will comply with all non point
with such provisions or this permit shalgbe doomed rovaked.
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, and
All roof coverings to be class "C" or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(We) agree to save, Indemnity and keep harmless the City of Cupertino against liabilities,
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J
judgments, costs and expenses which may In any way accrue against said City n consequence
of'he granting onhispermit.
SIGNATURE OF CANT 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
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