R 4845 PERMIT q_ 4845
APPLICATION FOR CITY OF CUPERTINO NUMBER
R—
PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(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
18(90 RESIDENTIAL--%L_COMMERCIAL OTHER
OWNER'S . HAZARDOUS FIRE AREA
-�(�1 VES ❑ If yes—I understand that a Class A
NAME //Ir /1��1•h-sJtl �I 1 �Cw/• NO ❑ roof assembly is required.
Initiel I.C.B.O.a
ADDRESS
198-)p C.4n Lr LAyp EXISTING ROOF COVERING
+�
PHONE 2f Q NUMBER OF EXISTING COVERINGS
CONTRACTOR
&
NAME 'kC/s ILLI
• hDI f TO BE REMOVED TO BE RETAINED
• ADDRESSto TYPE OF ROOF COVERING
CITY&ZIP 4o ) L,c1n d1-+�C.
EXISTING
PHONE—( b b) 29y- Yy00 BUILT-UP ROOF ❑
LICENSE ` 7
NUMBER h,
C -
LICENSED CO—NTflACTORS DECLARATION ASPHALT SHINGLES
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES 1:17000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effec
License
_ WOOD SHINGLES ❑
License Claes Lie.Number
2 IRO OTHER(SPECIFY) ❑
Data Contractor
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor,License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF 1:1applicant for such permit to file a signed statement that he Is II ed pursuant to the provisions
of the Contractors License Lew(Chapter B(commencing with edl n 7000)of Division 3 of the /
Business and Professions Code)or that he Is exempt therefry the basis for the alleged ASPHALT SHINGLES �I
exemption.Any violation of Section 7031.5 by any applicant ap subjects the applicant to
e civil penalty of not more than five hundretl tlollare($500) :
01,as owner of he property,or my employees witgqAag a Is compensation,will do WOOD SHAKES ❑
the work,and the structure Is not intended or offered for sell c 44,Business and Profes-
alone Code:The Contractor's License Law does not apply nor of property who builds or WOOD SHINGLES
Improves thereon,and who does such work N LLor h e own employees,provided that ❑
such improvements are not Intended or offer4 or eel hoWevar,the building or Improvement
lose Id within one year of completion,th oWner. or if have the burden of proving that he did ❑
not build or Improve for purpose of sale OTHER(SPECIFY)
El 1.as owner of the Property,am exclu tyI9y contracting with licensed contactors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law tloes not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who Was or Improves thereon,and who contracts for such projects
wllh a contractors)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
[JI am exempt under Sec. ,B a P.C.for this reason
Owner gate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
�
I hereby affirm under penalty of perjury one of the following declaration: U
❑1 have and will maintain a Certificate of Consent to self insure for Worker's Compensation, BUlldln 91 S�
as provided for by Section 3700 of the Labor Code,for he performance of the work for which this 2 p/ g - —
permit Is Issued L// �/U 6 '000 �O
( E]
I have and will maintain Workers Compensation Insurance,as required by Soctlon 3700 of Seismic
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's Total Compensation
l�eurLnce ce'r1�Tsr and Policy number are: 9 I00- S
Carrier ^�JJ Policy No. 2� ✓�� ���g PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed II the permit Is for one hundred dollen($100)100)or lees.)
I certify that In the performance of the work for which this permit is Issued, shall not employ �•� �- "
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali- All roofs shall be inspected prior o any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Data 4 -X Applicant -.ON Ila, L4,-- inspection,I agree to remove all new materials for inspection.
NOTICE TO A PLICANT: after makou
subject to the Workers'Compefnsetlon previsionis of the Labor Coca you mCertificate of Exemtion,ust forthwli hbecome comply Applicant understands and will comply with all non point
with such provisions or his permit sholebe deemed revoked. Source regulations.
I certify that I have read this application and state that he above Information Is correct.I agree
to comply with all city and county ordinances and a tete laws relating to building Construction,and All roc verings to be class.0°Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes. )
(Wel agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,teat.end expenses which may In any way accrue against said Chy In eonsaquanca - _
of the granting of this permit. SIGNATUHL OF APPLICANT u- "° ° '" ATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP.
.1996
INSP. DATE INSP. DATE INSP.
TEAR OFF INSPECTION: BATTENS: FINAL: CITY Or GUr"l,i u,v
INSP. DATE INSP. DATE INSP. - DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
nFcrrc rnpv