R 5356i<-10
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OFFICE COPY
PERMIT R_ 5356
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION N -
REROOF PERMIT (408) 777-3228 K NOT STARTED
HI leo DA F PE ISSUANCE OR
FRO STC INSPECTION.
BUILDING ADDRESS
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YCOMMEYRCIAL— 5 1999
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RESIDENTIAL
THER
OWNER'S
-RD S FI REA
VES ❑ It yea–I ul
NAME
roof assembly is required.
NO �Vel Initial I.C.B.O. #
INSISTING ROOF COVERING
ADDRESS
PH04ErWM) ,
NUMBER OF EXISTING COVERINGS
CONTRAC R' r 0
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS
TYPE OF ROOF COVERING
PHONE
BUILT-UP ROOF ❑
LICENSE 7
_
NUMBER Q
ASPHALT SHINGLES ❑
LICENSED CONTR CTORSDECLARAT10N
i hereby affirm that I am licensed under provisions of Chapter g (commencing with Section
WOOD SHAKES
7000) of Division 3 of the Business and Professions Code, and my license Is In full force and
effect. —
WOOD SHINGLES
License Class Lie. Number IL/�/••"�M<7 ,
"'
OTHER (SPECIFY) ❑
Dale Contractor
OWNER -BUILDER DECLARATION
PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the lollowin reason.
(Sec. 7031 5, Business and Professions Code: Any city or county which requires a permit to
construct, el tor, Improve. demolish, or repair any structure, prior to Its issuance, also requires the
applicant for such permit to Ills a signed statement that he le licensed pursuant to the provlalons
of the Contractor's License Law (Chapter a (commencing with Section 7000) of Division 3 of the
BUILT-UP ROOF ❑
Business and Professions Code) or that he Is pt therefrom and the basis for the a ed
exemption. Any violation of Section 7031.5b y epplicam for a permit subjectsthe apple an
a civ penalty of not more than live hundr dollars (5500).):
ASPHALT SHINGLES ❑
I, as owner of the properly, or m mployees with wages as their sole cam ones o , will do
WOOD $ ES ❑
Ih w k, and the structure Is not ntletl or offered for sale (Bat , Bust esu a
alone Code: The Contractor's nse Law does nal apply to n o prop wh ullds or
Improves
OOD SHINGLE$ ❑
thereon, and who does h work himself or oug hisploy s, pro ed thatsuch Improvements are not Intends r offered to e. If, ho aveI or imp vementIs
sold within one year of completion,t own lder will he thn ravingt the did
OTHER(SPECIFY)
not build or Improve for purpose of sal
❑I. as owner of the property, am ext lively contracting wit licontractors to construct
the project (Sec. 7044, Business and P fesslons Code: The C ntractor's License Lew does not
apply to an owner of property who build r Improves thereon, a who contracts for such projects
PROVIDE I.C.B.O. REPORT NO.
with a contractors) licensed pursuant t the Contractor's Ucon a Law.
❑ I am exempt under Sec. ,B & P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner ooze
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm untler penalty of perjury one of the following declaration:
❑ I have and will Certificate Consent
/7�j
� � 7
maintain a of to selidnsure for Worker's Compensation,
as provided for by Section 3700 o1 the Labor Code, for the performance of the work for which this
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Q 182196
v1OL.a/
Building
pe�r�J{t la laeuetl.
7q I have end will maintain Worker's Compeneetlon Insurance, es required by Sectlan 3700 0l
O 1
$61Sf1'lIC ( V
the L bor Cade, for the ped mance of the work for which this permit Is Issuetl. My Worker's
/ -� ��
Comps e'en In ren e r reM olicy nu rare:
Total (1–/ r
/
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Carrie Policy No
PERMIT AUTHORIZATION
DATE
CERTIFI EOF E%EMPTION FROM WORKERS'
OMPON INSURANCE NAD
(This section need not be completed if If the the permit Is for one hundred dollars ($100) or lava.)
I certify that in the performance of the work for which this permit Is Issued, 1 shall not employ
All roofs shall be inspected prior to any roofing material being
any person to any manner so as to become subject to the Workers' Compensation Laws of Call.
' fornia.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove allinew materials for inspection.
NOT CE TO PLICANT: It, aftertion, ou
subject t. the Workers' Compensation proivieloos of thelcate Laborr Coda, of you must fo thwlithbecome comply
Applicant understands and will Comply With ail non point
with such Provisions or this permit shall be deemed 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 ounty ordinances and state laws relating to building construction, and
All of coverings better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes. -
ntoss'3(or
C 1
(We) agree to save. indemnity and keep harmless the City of Cupertino against liabilities,
O
ludgmants, costs and expenses which may In any way accrue against said City In consequence
of the granting of this permit.
SIGN TURE OF APPL T 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