R 4919s
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PERMIT R. 49 19
APPLICATION FOR CITY OF CUPERTINO NUMBER
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 UST CALLED INSPECTION.
BUILDING ADDRESS
LL G (
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
n I
®� L 0 � LO v C
VES ❑ If yes I understand #tad. Class A
NAME )L -X ' "
s
roof assemdy is regldreA.
is req
NO Imaal I.C.B.O. #
L� �1
CuP�?
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
ADDRESS/OG `;— ��Na��- 07.
PHONE
CONTRACTOR'S
,r Qp
NAME 9 ��`�
TO BE REMOVED TO BE RETAINED
ADDRESS7 L Da w L `� /1. /D4
r
TYPE OF ROOF COVERING
CITY & ZIP /7y C•_
EXISTING
�1p
y- �-T S3
PHONED I -
BUILT-UP ROOF ❑
LICENSE 2 3,7
NUMBER p
ASPHALT SHINGLES
11NUMBER
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8 (commencing with Section
WOOD SHAKES 210,
7000) of Division 3 of the Business and Professions Code, and my license Is In full force and
effect.
1, 7
WOOD WOOD SHINGLES ❑
License Class Loc. Number
S (j./ 17Cy L�
Dela —• Contractor
OTHER (SPECIFY) ❑
OWNERBUILDERD LARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
PROPOSED
ISec. 7031.5, Business and Professions Code:Any city or county whit quire° a permit to
construct, alter, Improve. tlemoll1h. or repair any°Iructum, prior to I" jfhp also requires the
1
BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he is licensed pure to he provisions
of the Contractors License Law (Chapter 8 (commencing with Secilion,706074 Division 3 of the
Business and Professions Code) or that he Is exempt therefron) tl the ba r the alleged
ASPHALT SHINGLES ❑
exemption. Any violation of Section 7031.5 by any applicant for aper le applicant to
a civil penalty of net more than five hundred dollars ($500).)r'
es
WOOD SHAKES 0
01, as owner of the property, or my employee° with. sal Ir ole pensation, will do
the work, the Is Intended
and structure not or offs //ao 44,�Gelness and Proles.
alone Cotle: The Contractors License Law tloes of, 1Yt n aro/'property builds
who or
Improves thereon, and who does such work hlrpeh r I �a his owry4mployeas, provided that
WOOD SHINGLES ❑
such Improvements are not Intended or alter or• I, h wave
a J,the building or Improvement
Is sold within one year of completion, the owner -0A er Ir vs the burden of proving that he did
not build or Improve for purpose of sale.).
OTHER (SPECIFY) ❑
❑ 1, as owner of the property, am exclusively contract ng with licensed contractors to construct
the protect (Sec. 7044, Business and Profession Coda: 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 Ccneactor(s) licensed pursuant to the Contractor's License Law.
0I am exempt under Sec. ,B # P. C. or this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner De1B
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
01 have and will maintain a Certificate of Consent to sell -insure for Worker's Compensation,
as provided for by Section 3700 of the labor Code, for the performance of the work for which this
11/�Q
��
Buildin
permit is Issued.
'
p
Workers Compensation
ton ce,this as required by Section
01 have and wool maithe 's L,
labor
/ �7 ��
Seismic
the pitlrf
work which
Code, for the performance of the work for which ills permit 16 Issued. My Worker's
Is I Worker's
Compeneatlon Insurance
(//-
LUt
carrier and Policy number are:
Total _
Carrier Policy No.
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the permit Is for one hundred dollars ($100) or less.)
I certify that In the performance of the work for rich thio parmlt Is issued, shall not employ
All roofr. shall be irldpItcled prior to any r ng mat alb in
any person In any manner so as to become sub to the Workare' Cempanaason Laws of Cak-
form°'4'
installed. If a roof is installed witho first obtaining an
Date -� Applicant �■-�
inspection, I agree to remove all new materials for inspection.
NOTICEfafter making foluubecome
subto the Worrkers'Compensationn proviprovisions of the Labor Code, you mstfethwihomply
Applicant understands and will comply with all non point
with such provisions or this permit shalgbe damned revoked.
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
to be class "C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
Altlofcoverings
spection purposes.
(We) agree Is save, and keep harmless the Cory of Cupertino liabilities,
judgments, expenses y In con
ls, oat° and expenses which may in any way accrue against said Clry In consequence
ence
StGNATURE OFA PLICANT DATE
the limping
of the grennnp 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
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