R 5754 sbl s o Jnr
APPLICATION FOR ICI-Y O CI P)RTO NUMBERPERM
INSPECTION
R- 5 7 5 4 .
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 LAST CALLED INSPECTION.
• BUILDING ADDRESS - c Y
lS• ORT VG RESIDENTIAL ,` COMMERCIAL OTHER—
OWNER'S
THER
OWNER'S,DnC Q HAZARDOUS FIRE AREA
VDV RQ1 I lrF'�P YES ❑ If assembly
required.
NO
Class
NAME... roof assembly is required.
NO 11Initial I.C.B.O.N
ADDRESS ( LQ /X05kT
EXISTING ROOF COVERING
PHONE 7O - g Q •NUMBER OF EXISTING COVERINGS 47A(t
CONTRACTOR'S
�' fcL T• RI�'G'E/'c� TO BE REMOVED_ ,l�L� TO BE RETAINED
NAME
ADDRESS
clTv s ZIP ��� ✓]��X1.2- pG SGI�(/IC( / , TYPE OF ROOF COVERING
EXISTING/ /Yp IY/r
PHONE (. FL ! �lm BUILT-UP ROOF ❑
NUMBER p 7�S.E'�- ASPHALT SHINGLES ❑ ',
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the.Buslness and Professions Code,and my license Is In full force and
affect.
License cissa v C 3 ` WOOD SHINGLES ElLlc.Number
Data �—_�7— ??- Contractor C�+A<< T /66-J5nl OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
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 requlrea,a permit to
construct,alter.Improve,demolish,or repair any structure,prior to Its Issuance,also require&the BUILT-UP ROOF
applicant for such permit to file a signed statement that he Is licensed pursuant to he provisions
of the se en Pr's License Law,0,that 9 15 .. ptp with Section 7000)of Division he 3 of the
ex a exemption
and Pro lotion f Code)or her he is exempt therefrom and the su bash for the alleged ASPHALT SHINGLES
exemption.Any violation of Section hundred
by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred employees
dollars with
wag.);
r ❑I,k,and
er the structure
1 not I my tended oyeeered wages(S e.7heir sale compensationaand
prlll do a•lWOOD SHAKES ❑
he work,entl ins alruclure la not Inlantletl or offered for eels Isac.7044,Suetwasend Protea' p s,1
slons Code:The Contractor's License Lew does not apply to an owner of propety who builds oF3 ?` a WOOD SHINGLES
Improves hereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.If,however,the bulltling or Improvement �p��p
is sold within one year of camplellon,the owner-builder will have the burden of proving that in `� *%R(SPECIFY) ❑
not build or Improve for purpose of sale.).
r']1,as owner of the property,am exclusively contracting with licensed contra ctpre to cone c L
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not
apply to an owner of property who builds or improves hereon,and who contracts for such ploeFtt Ur -PROVIDE I.C.B.O.REPORT N0.
"
with a contractor(s)licensed pursuant to the Contractor's License Law. VV f1 PROVIDE MFGR.INSTALLATION SPECS.
E]I 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:
❑I have aptly III maintain a of the Lab of Consent to self-insure Im Worker's Compenshtlon, Building �/
e6 ]I have
tl for b Section 3700 0l the Labor Code,for the performance for
of the work for which tole i x/1/}NI' (7/� 7 Q
perml la Issued. Seismic
have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the door Code,for the performance of the work for which this permit Is Issued,My Worker's '7
Compeneerlon Insurancesettler and Policy number are: p Total
Carrier xSr/p• fLlAl� Policy No.� f4MI• PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the permit Is for one hundred dollars(§100)I00)o or leas.)
I certify that In the performance of the work for which this permit Is Issued.I shell not'"Ito
any parson In any manner so no to became suti' 1 the Workers'Com onset on Laws of tau• All roofs shall be inspected prior to any roofing material being
fornix. installed. If a roof is installed without first obtaining an
Date '2-17-78' Applicant inspection,I agree to remove all new materials for inspection.
NOT CE APPLICANT. should
subject to theOWorrkera'C mpelnsatior provisions of theficate Labor Code.at You tio ustufothwi hbecome comply Applicant understands and will Comply With all 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&gree
to comply with all city and county ordinances and state laws relating to building Construction,and All roof coverings to be class'e or better.
hereby authorize representatives of this city to enter upon the ebova-monloned property for In.
specaon purposes.
(We)agree to asva,Indemnity and keep harmless the City of Cupertino against liabitnles,
judgmenta,costa and expenaea which may In any way accrue against said City In consequence
epos gmnring ofInia 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