R 4555 APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 4 5 5 5
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 ADDpRE�SS���r�, SC
�s� � }�
L V X00 G7C W 4z RESIDENTIAL—%41-0COMMERCIAL OTHER
OWNER'S � � HAZARDOUS FIRE AREA
NAME—v/L r'7"r r/� . 5 / YES ❑ If yes-I understand that a Class A
roof assembly is required.
NO Initial I.C.B.O.M
I EXISTING ROOF
ADDRESS ` (�'p^ �Qp COVERING
PHONE 7`�O / 6 ^ ILIO NUMBER OF EXISTING COVERINGS
CONTRAC7�OR'S
r/CONp,� wTO BE REMOVED TO BE RETAINED
NAME—// �- �I�U
ADDRESS ��6 Z L � M• TYPE OF ROOF COVERING
CITY&ZIP iJJ
(� o EXISTING
PHONE 40909LG 9'Ta30 BUILT-UP ROOF ❑
LICENSE L - ❑
NUMBER O S 4lGJQ ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is In full force and
effect.
i( WOOD SHINGLES ❑
Cleanse Claes Lic.Number
Del. contreeor OTHER(SPECIFY)
OWNER the Conn D Cs RAnON
License PROPOSED
1 hereby edBu met am exempt from the e: Any
or cotta Law for the following reason.
(Sec.construct,
It Business and demolish,
or re Code: Any city or county which requires a permit to
applicant
altar,Improve,demola si nrepeatanynthatstructure,prior to Its Issuance,pursuant also requires the BUILT-UP ROOF ❑
applicant for such permit a flaw a signed r 9( m m that he Is licensed pursuant to the provolone
• of the ssContractor'sandPProfessions
Lew(Chapter a(commenting with Section and 7000)al for the 3 of the Gt 0 gwo
Business and vi oeion of Code)or 0311 he Is exempt therefrom and the baso for the alleged ASPHALT SHINGLES Gl 0 LL
exemption.Any f of more
of Section hundred
by any s($6 0) for a permit subjects me applicant to
a civil penalty of not more Then Ilve huntlretl tlollare with
wag.): AUG �0
❑Las and
er the structure
I not I tendedmy employees redh r sale(Sec.7044,
compensation,will s. WOOD SHAKES 1§5
the work,antl the structure Is not Intended or offered for sale(Sea owner
of ropertas and Proles-
Improvsslons h:The Contractors doessuchworkhisnot apply ghhisowneployees,proidey who dsor WOODSHINGI_t�jY
Improves thereon,and who does such work offered
or.If,ho his own employees,Improvement
provided that
such Improvements are not Intended or offered for sale.If,however,me building or Improvement IJP LUYtH 1 '♦1
-19
Is sold within one year of completion,the owner-builder will have the bureen of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.). _
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code: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 contractor(a)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B 8 P.C.for this reason
Owner Oats
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I
hreby affirm under penalty of perjury one of the following declaration:
4have and will maintain a Certificate of Consent to selMnsure for Workers Compensation, BUlldln0-4
es rovltlad for by Section 3700 of the Labor Code,for the performance of the work or which this
permit is issued. $61SmIC
❑1 have and will mei Wor era Compensation Insurance,as required by Section 3700 of ' 1
the Labor for t o ce of the work for which this permit Is issued,My Workers 1\ Total
Co ane n bar are:
Carrie Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NCO
(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 which this permit Is Issued,I shell not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell. All roofs,shall be inspected prior to any roofing m eria Ing
fornix' installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: after subject to the Workers'Compelnsation provisionis of tthe11cate LaborCode,you must Io thwllthbcomply Applicant understands and will comply with all non point
with such provisions or this permit ehalfjbe deemed revoked, source regulations.
I certify that I have read this appileetlon 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 All roofings I cl S"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In. �� �
epection purposes.
(We)agree to save,Indemnity and keep harmless the Clry of Cupertino agalnel Ilebllltlee.
• Wegmenta,costa antl expenses which may In any way accrue against said City In consequence -SANATURE OF APPLICANT
of the granting of this Permit. DDTE
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