R 5968 PERMIT R_ 5 9 6 8
APPLICATION FOR CITY OF CUPERTINO NUMBER
R-
PERM 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 ��
/ RESIDENTIAL COMMERCIAL OTHER
O NER' HAZARDOUS FIRE AREA -
YES ❑ If yes-I understand that a Class A
NAME roof assembly is required.
NO ❑ Initial I.C.B.O.x
ADDRESS EXISTING ROOF COVERING
PHONE — I NUMBER OF EXISTING COVERINGS
CONTRAC ORS
NAME TO BE REMOVED-/—TO BE RETAINED
ADDRESS ��;/.t� /H ; /� —_/„ C� g/ EXISTING
TYPE OF ROOF COVERING
CITY&ZIP (,�0�' / (/��(,. 2 (Fx>�L� J/
PHONE '�j (1 ��? J BUILT-UP ROOF ❑
CENSE
NUMBER ASPHALT SHINGLES ❑
LIC ED CONTRACTORS DECLARATION - ,�y
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES h�I
7000(of Division 3 of the Business and Professions Code,and my license le In lull force and %
effect. ` `/� .��,�/���� WOOD SHINGLES
License Claes Lle.Number _� 7 —iZL _ ❑
Dale Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED Q
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to 11p
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requireet BUILT-UP ROOF e [�
applicant for such permit to file a signed statement that he Is licensed pursuant to the provls n %
of the Contractors License law(Chapter 8(commencing with Section 7000)of Division 10
• Business and Professions Code)or that he Is exempt therefrom and the basis for the ell g ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant lora permit subjects the applicant ld �I ��
a civil penalty of not more than five hundred dollars($500).): V �•J
❑I,as owner of theproperty,or my employees with wages as their sole compensatlon,wiildo WOOD SHAKES `
the work,and the structure Is not intended or offered for sale(Sec.7044,Businea9 end Profen-
slons Code:The Contractor's License Lew does not apply to an owner of property who builds or
Improves thereon,and who does such work himself or through his own employees,provided that OOD SHINGLES G\� El
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
B sold within one year of completion,the owner-builder 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.7044,Business and Professions Cope:The Contractors 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 contractors license Lew. PROVIDE MFGR.INSTALLATION SPECS./6
❑ e
em exempt under Sec. ,B P.C.for this reason
Owner _ Data
WORKER'S COMPENSATION DECLARAATIOTION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: I��
I have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
El
permit Is Issued. $- IO —92) Seismic 1
❑1 have and will maintain Worker's CVilifensation Insurance,as required by Section 3700 of
the Labor C dI q8
for the p°t'arm nc°o h w rk for which this permit is Issued.My Worker's p�Grp
Compens n Insurance copier and c nu oar er _ Total
i
carrier yNa. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORE S'
COMPENSATION INSURANCE N.CQ Q
(This section need not os completed if the permit is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit Is issued,I shall not employ
any person in any manner so as to became subject to the Workers'Compensatlon Laws of Cell- A roofs shall be inspected prior to any roofing material being
fornia., installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
become
subject to the Worers'Compelnsetlon provisionafter makinis of tthelLaborr Code,cate yoof Exemlu mustufothwilith comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. Source regulations.
1 certify that I have read this application and state that the above information is correct.t agree
to comply with as 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-mentlonod property for In.
spection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities, Ca.
judgments,costs and expenses which may In any way accrue against°aid City In consequence
• of the granting of this 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