R 46730
OFFICE rnpv
NUMBER Rie 4673
APPLICATION FOR CITY of CUPERTINO
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
S0 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
—1
7 5/ 0,7
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
- HAZARDOUS FIRE AREA
VES Ing - I understand that a Class A
NAME
roof assembly is required.
NO Initial I.C.B.O. q
�+
ADDRESS—+�u�'
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
TO BE REMOVED Q TO BE RETAINED
PHONE ( —
CONTRACTO
NAME
7
ADDRESS -/TYPE
W/r/" �O ��� y-
OF ROOF COVERING
t CITY & ZIP F"7
EXISTING
o -
{�^-7
G — -74/� O
PHONE Ori
BUILT-UP ROOF ❑
LICENSE
NUMBER (o 0 6
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B (commencing with Section
WOOD SHAKES
7000) of 134,16ion 3 of the Business and Professions Cade, and my license Is In full force and
meet
o / 6
WOOD SHINGLES ❑
License Clea Lic. Number o i0
9�
OTHER (SPECIFY) ❑
Data
_
a� A - �
I-BUCont I DE DE ION
OWNER -the
hereby affirm that am exempt from the Contractor's Llcenee Law for the following reason,
Conn is License
PROPOSED
(Sec. 7031.5, Business and Profedemolish, or rep Cotle: Any city or count' which requires a permit a
allay, improve, rlor resuancs, also requires the
BUILT-UP MAY 3 0 1996
appilcconstruct,
to file signed statement
applicant for such permit Ills a signed statemecenaetl the
ROOF
use pu 00) of
pro of the
a
of the Contractor's License Lew (Chapter 6 (comedWn ]000) of Division 3 0l the
Business Professions
and Code) or met he Is eal fid the basis for the alleged
ASPHALT SHINGLES CI I Y Ur ❑L. ecru IMU
exemption. Any vlalatlon of Section ]031.5 by anyIl6uble<ta the applicant to
e civil penalty of not more then five huntlred tlonel,
P
es owner of the property. or my employeketheir sole compensation, will do
WDDD SHAKE$ ❑the
work, and the structure la not Intended rollyy Sec. 7044, Bualneea antl Profes-
elonaCode:TheContrector'aLlcenseL doseanownerolproperrywhobullesarWOOD
thereon, and who does such r bimgh his own employees, provided that
such Improvements are not Intended ffer d't0 a)arlf, however, the building or Improvement
SHINGLESImproves ❑
Is sold within one year of completion, the r-bullder will have the burden of proving that he did
OTHER (SPECIFY) ❑toxPilRAi�
not build or Improve for purpose of ea19Jr ✓
El 1, as owner of the property, am exclus vely contracting with licensed contractors to construct
the (Sec. 7044, Business Professions Code: The Contractor's License Law does
/
�O p -C p. �r h1/nLy
PROVIDE I.C.B.O. REPORT NO. JIM ! r/C.I IRI
project and not
apply to an owner of property who builds or Improves, thereon, and who contracts for such projects
with a contractons) licensed pursuant to the Contractors License Law.
❑ 1 am exempt under Sec. ,B a P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Aare
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Compensation,BUlldln
for by Section
-
g
as provided 3700 of the Labor Code, for the performance of the work for which this
permit Is Issued.
.S / 7/
a 2-&
*W have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
1h
SeIsmlc 0
_)h6 Labor Code, for the performance of the work for which this permit Is Issued. My Worker's
Compensation Insurance carrier Policy
V
and number are:
�u a" &.,d 14 L im—.yl�04-01
Total 41
PERMIT AUTHORIZATION
DATE
Carrier Policy No.
CERTIF ATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C❑
(This section need not be completed If the permit Is for one hundred dollars (5100) or less.)
I
certify that In the performance of the work for which this permit Is Issued I shall not employ
s Shall be—inspected prior to any roofing material being
any person in any manner so as to become subject to the Workers' Compensation Laws of Ceti-
fornia.
installed. If a roof is installed without first obtaining an
Data Applicant
inspection, I agree to remove all new materials for inspection.
subjectAto the Workers' It, aftermaking
is of thleicate of Laborr Code,Exemption,youyou should become
you must forthwith comply
Applicant understands and will Comply with all non point
p Y
with such provisionspermitahation deemed revokethat
SOUfCe regulations.
have rad the,
state that the above Information leCorrect. lagree
<eply IhelIhave reatlolety
ordinances ting
to with all and county ordinances
All roof c cerin s to be class "C" or better.
remply rcityep se to erste upon the above-mentioned
hereby authorize representatives of this city to enter upon the above-mentioned property hr In-
d propertyfor
spection purposes.
(We) agree save, and keep hay the Cupertino Ilebll-----
��%��
s expensindemnes way e a ai y In u_against
judgments, coats and expenses which may In any way accrue against geld City In consequence
of me granting of this permit.
SIGNATUREAF 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 rnpv