99110172 oo r ?2 3 &-qsi` o �,3-
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) ]7]-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
IA BUILDING ADDRESS
Q �� RESIDENTIAL--X,COMMERCIAL OTHER
'OWNER'S HAZARDOUS FIRE AREA
-{
�- YES ❑ If yes-I understand that a Class A
NAME � e S'�GA7o i � f 6 NO ❑ roof assembly is required tial LC.B.O.IX
ADDRESS �� 06h?�IcJl"'/.� EXISTING ROOF COVERING
PHONE DFS04- 2�,2fa
NUMBER OF EXISTING COVERINGS 2
CONTRACTOR'S
NAME JeCwka t ,�� 1`n/4 /VC 7401 -TO BE REMOVED_/�_TO BE RETAINED
1
ADDRESS TYPE OF ROOF COVERING
/ N �•
CITY&ZIP 677 KIQS � SS
////`
O –1 EXISTING
PHONE-J&4f 9W—/777 BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
]000)of Division 3 of the Business and Professions Code,and my license is in full force and
effect.
G 32+ CZO 1 O WOOD SHINGLES 1=1
License Class Lie.Number 7-
Data/a—31-00Conlrador OTHER(SPECIFY)
OWNER-BUILDER DECLARATIO 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 requires a permit to
construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires t F IQI'
applicant for such permit to file a signed statement that he is licensed pursuant to r i
of the Contractor's License Law(Chapter 9(commencing with Sectio 00 1
Business and Professions Code)or that ho is exempt Iher n e HINGL S
exemption.Any violation of Section 7031.5 by any applicant a ubl e t
a civil penalty of not more than live nor dred dollars($500).) Q Q
C]1,as owner of the property,or my employees with wage rso mpensation, KES D
the work,and the structure is not intended or offered for sal ec.7044, in ��D��D$$$$!!!!IIIIHH----��II p��I�I
Bions Code:The Contractor's License Law does s not apply to an s r of p e wh u No V
improves o thereon,and who does such work himself or through ev am b is 2
such improvements are not completion.
or owner for sale. ill however,, buil a r1(]
n to ulld or
prove for purpose
sale.). will have the suing that he \ AJ
not bulltl or improve for purpose of sale.). p/
❑Les (Sec.of the property•am exclusively contra a:Keith Ii d co . y
the project(Sec.]044,Business and Professions a: he C n R VIDE LC.B.O�R -RT N�
apply to an owner of property pwho ursuant or improvas thereon,a n ct is
with acontmctogs)licensed pursuant to the Con tractor's been a PROVIDE MF GR. INSTALLATIONS EC
❑1 am exempt under Sec. ,8 8 P.C.for this reason -
Owner Data APPLICATION DATE VALUATION PERMi i FEE*
WORKER'S COMPENSATION DECLARATION
Fj I have
affirm under penalty of perjury one of the following declaration: _ ��` Yj goo
Q
haveantl will maintain a Certificate r Consent to self-insure for Worker's Compensation,htis Building
as mit its is for by Section 3700 of the Lobar Cotle,for the performance of the work for which this
permit is issued.
❑I have and will maintain Worker's Compensation Insurance,pe required issued.
d.My 3]00 of ^ � �� Seismic
the Leber Code,for the performance of the work for which this permit is issued.My Workers /nom
Cempens,ayti n Insurance carrier and Policy number am: j����QQ V Tote
carrier fYifoyni 7 C`t� Policy No.t1(/V 7 7 �?7—D/ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I] /]�
(This section need not be completed if the permit is for one hundr d d rs($100)or less.) �LI-�
I certify that in the performance of the wo fo which tois permit issue I shall not employ
any person in any manner so as to berome utile to thew kern' _pen sten Lawe of car- All roofs shall be inspected prior to any roofing material being
fernia ( �/t installed. If a roof is installed without first obtaining an
Date l` I "' . 9 APPlica inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after ma is Certificate of Exemption,you should become Applicant enders ds and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP P Y p
with such provisions or this permit shall be deemed revoked, source reg Ulatio S.
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 II r f covering to classr better.
hereby authorize representatives of this city to enter upon the abovo-mentioned property for in. 7 �f
spection purposes. I IJ✓�_�
(We)agree to save,indemnify and keep harmless the City of Cupertino against Ilabilities,
judgments,costs and expenses which may to any way accrue against said City in consequenceE OF APPLICANT DATE
of the granting of this permit.
•, PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
f INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL: -
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY