R 4896 PERMIT R_ 489
6
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
( u(7 ; x/LSca, V RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
` 1' ' YES EJ If yes—I understand that a Class A
NAME
r o T o W ti root assembly is required.
�� �7 NO ❑ Initial LC.B.O.g
ADDR SB \ �J Imo e PJ q C n» Cil `I S b/S EXISTING ROOF COVERING
LA0?' ) �•
PHONE NUMBER OF EXISTING COVERINGS '
7- � O 1 ,
J� CONTRACTOR'S O
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS18��,� Z TYPE OF ROOF COVERING
CITY&ZIP az:-K,
.�- 96w
_ EXISTING
PHONE l/'�o`f� CT / �'li7 by BUILT-UP ROOF
LICENSE ❑
NUMBER O p ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES El
700
of Division 3 0l the Business and Professions Code,and my license Is In lull force and /
affect.
G- 3 LicWOOD SHINGLES ❑ //
License Class
.Number
D ats I° `I Con.rac OTHER(SPECIFY) ❑ .
OWNER the oER DE ION PROPOSED
I hereby affirm that I am exempt from the e: Anc it county
Law for the following reason. p !�
(Sec.7031 It Business and demolish,
or rep Code: Any arty or county which requires a permit to P M I
ID
construct,alter,Improve,demolish, nrepeatany nstructure,priorto Its Issuance,also eequlreethe BUILT-UP ROOF
applicant for Contractor's
permit a flaw(Chapter 9(commencing
that g it licensed pursuant to the provisions
the q�}
of the ss and
License Law(Chapter a(commencing with Section 7000)of for the ale the ASPHALT SHINGLES OCT❑ 9 1996
•
Business end violation Of Code)or the.he Is exempt therefrom and the basis for the alleged
exemption.Anyviolationo t on of Section 7031.5 by any applicant for a permit subjects the eppllcant to
e civil0penalty of not more than five hundred deflate with
wage WOOD SHAKES (,I I t ui�-n�upLm I INO
❑I,as owner of the property,t I to dedemployees with wegee as their sole compensation,wall s. Ly
the work,and the ontr structure Is not Intended or offered for Bale(Sea owner
of property entl builds
or
irons Code:The Contractor's Licence Lew dome not apply to an owner of property who provided
t or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such improvements are net Intendedn,or owned for sear.If,however,the burden
pr or Improvement
Is not ld bull or
year of for purpose
sTse owner-builder will have the burden ql proving tsar he did OTHER(SPECIFY)
❑
not build or Improve/or purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(See.7044,Business and Professions Code: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 Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS.
❑1 am 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:
0 have and.111 maintain a Certificate of Consent to self-insure for Worker's Compensation, '�Il Ob Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is Issued. $eISmIC
2f)have and will maintain Worker's Compensation Insurance,as required by Section 3700 of I v n a
the Labor Code,for the performance of the work for which this permit is issued.My Worker's '1 9
Compensation lnsurwn acarrler tlPollcy number are: Toter __
Carrier _�� Policy No.�llz/ /-9G PERMIT AUT RIZATION DATE
-• CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need no.be completed it the permit le for one hundred dollars($100)or less.)
I certify that In the performance of the work for which It Is Issued shell not employ
u
any person in any manner so as to become sub' a Worker p nestled a of cell. All roofs shall be inspected prior to any roofing material being
lornia' installed. If a roof is installed without first obtaining an
Date /� Applican inspection,I agree to remove all new materials for inspection.
NOTIOIE TO APPLICANT. II,after making this r to of E%wmPlioa,you should become A licant understands and will comply with all non
subject to the Workers'Compensation provisions I th abor Code,you must forthwith comply It P Y point
with such provisions or this permit shell be deems yoked. source regulations.
I certify that 1 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 coverin IaSs"C"or better.
hereby authorize representatives of this City to enter upon the above-mentioned property for In-
spection purposes.
Iwo)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, �� 6
judgments,costs and expenses which may In any way accrue against said City In consequence
of the granting of this Permit. SI E OFAPPLICANT DATP
• 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