R 4955 PERMIT R_ 4 9 5 5 .
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
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WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/
! `0 5— �` Gi �/l U RESIDENTIAL COMMERCIAL OTHER
OWNER'S - r HAZARDOUS FIRE AREA
�Cv VES Cl If yes—I understand that a Class A
NAME �{'( IT / ( I� --. 111 V roof assembly is required
Initial I.C.B.O.M
ADDRESS- l s 5 f—�I G �U� EXISTING ROOF COVERING
PHONE 4-75- 014? NUMBER OF EXISTING COVERINGS - r
CONTRACTOR'S
I'
AME ROD L/U � 0/ / �\C �/r C TO BE REMOVED TO BE RETAINED
NU` (
ADIDRESS � 1l G{ ?. �-Q m r`Cf CRUZ TYPE OF ROOF COVERING
CITY&ZIP / 6
L� 5-6(P,;L- EXISTING
PHONE ? �`S ` 0�� r,-,� BUILT-UP ROOF
LICENSE [ r� —� �O
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
affect WOOD SHINGLES �•
License Cleaa �— Lie.Number
Date Contractor W OTHER(SPECIFY) q/641 03 J❑
OWNER-BUILDER DECLARATION PROPOSED Lr ra99
hereby affirm that I am exempt from the Contractors License Law for the following reason. (, L�
(Sac.7031.5,Business and Professions Code: Any city or county which r Ire la permit to LFr A/
construct,alter,Improve,dar iah,or repair any structure,prior to its Issuance. orequires the BUILT-UP ROOF h/y
applicant for such permit to file a signed statement that he Is licensed puuI a rovisions /yam
' of the Contredore License Law(Chapter g(commencing with S Iop700)of 1 I 3 0l the
Business and Professions Code)or that he Is exempt therefrom th as to a alleged ASPHALT SHINGLES— G-1
exemption.Any vlDlation of Section 7031.5 by any appll ant orb permpplicent to
e civil penalty of not more than five hundred dollen 0 o
❑I,as owner of the property,or my employe It vma I Iq a perusal on,will do WOOD SHAKES
the work,and the structure Is not Intended or BfeWp ale 7 4,easiness and Proles- p p y
alone Code:The Committers License Low tl not X11 tiro' or BWproperty who builds or WOOD SHIN(�LFr��_ OV 1199Tf At CU'
Improves thereon,and who does such work,(jlm5 or traLpfffil/own employees,provided that
such Improvements are not Intended or offer etl P .Il,however,the building or Improvement l/1 L U �j
Is sold within one year of completion,the owner- ullder Ill have the burden of proving that he did OTHER(SPECIFY) rL"r"Irlirt UI '
not build or Improve for purpose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct //
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO. - J
qb
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractona)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
E]I am exempt under Sec. ,B 8 P.C.for this reason
Owner Dale
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
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I hereby affirm under penalty of perjury one of the following declaration: Q
❑I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, / Building r
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this O O
permit is Issued '�
r
L I have and will maintain Worker's Compensation Insurance.as r
❑ p mit is Issued.
d.MySectionWorks o1 oo $eISmIC l
the Labor Coda,for the performance of the work for which tole permit Is Issued.My Workers
Compensation Insurance carrier and Policy number are: Total
Carrier Policy No. PERMIT AUTHORIZATIDATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed it the permit Is for one hundred dollars($100)or less.)
I certify that In the performance of the work for hich this permll la Issued I shall not employ
any person in any manner so as to become sable to the Works Compensation Lawsof Cali• All roofs shell be inspected prior to any roofing material being
orma. O installed. If a roof is installed without first obtaining an
Date ` ' 9�v Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this erti icate of ram II n,you should become q Ilcant understands and will comply with all non point
subject to the Workare'Compenatlon provisions of the Lobar Code,y must forthwith comply PPI P Y P
with such provislone or this permit shalQbe deemed revoked. Source regulations.
I certify that I have read this application and stale that the above Information Is correct,I agree
to comply with sit city and county ordinances and state laws relating to building construction,and All f Verl s be class"C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
ep(We)agrpoeas.
(We)agrees save,Indemnand expenses
and keep armless the Clry of Cupertino y in con liabilities, /
judgments,
granting of this permit ee wnlcn may In any way accrue epelnet said City In consequence SIGN T OF APPLI CMT 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