R 5824I*
_•
OFFICE COPY
PERMIT
R_ 582 4.
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
'OR
WITHIN 100 DAYS OF PERMIT ISSUANCE
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
900 S•/c ✓r,�s �2cK- �I�v
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
t
YES ❑ If yes — I understand that a Class A
NAME /✓�G�.4CND
roof assembly is required.
NO ❑ Initial I.C.B.O.It
y 1 p)
ADDRESS /r // Z
EXISTING ROOF COVERING'
NUMBER OF EXISTING COVERINGS G,y
PHONE Nos - lz l b ,
CONTRACTOR
/'$
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS /6JV S
TYPE OF ROOF COVERING
clry a ZIP
EXISTING
Z 5; Z
PHONE t�0
BUILT-UP ROOF
NUMBER L Z 3 Z
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 0 (commencing with Section
WOOD SHAKES ❑
7000) OI Division 3 of the Business and Professions Code, and my license Is In lull force and
effect. G _ 3%Z
WOOD SHINGLES ❑
License Class Lic. Number
8
OTHER (SPECIFY) ❑
Date Contractor .Al'"a
OWNER-BUILDER DECLARATION
hereby affirm that I am exempt from the Contractor's License Lew for the following reason.
PROPOSED
is 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct, altar, Improve, demolish, or repair any structure, prior to its Issuance, also requires the
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
BUILT -UP ROOF [IJR
of the Contractors License Law (Chapter a (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he Is exempt therefrom and the basis for the alleged
ASPHALT SHINGLES
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars ($500).):
owner
pis for
WOOD SHAKES ❑
the0work eand the structure pot intended ofereldhfor sale (3 c. 7044, Business and Parse.
alone Code: The Contractor's License Law does not apply to an owner of property who builds or
thereon, and who does such work himself or through his own employees, provided that
WOOD SHINGLES El
such Improvements are not Intended or offered for sale. II, however, the building Or Improvement
Is sold within one year of completion, the owner-builder will have the burden 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 Contractors License Law does not
PROVIDE LC.B.O. REPORT NO.
apply to an owner of property who builds or Improves thereon, and who contracts for such projects
with a contractor(s) licensed pursuant to the Contractor's License Law.
❑ I em exempt under Sec. ,B 8 P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
owner isle
APPLINO PJ L)ATEJ
VALUATION
PERMIT FEE
W RKER'S COMPENSATION DECLARATION
hereby and under penalty of perjury one of the fallowing declaration:
maintain
for Worker's ❑I have
Consent theperformafor
- ®(j
Building
370 of the Latbof
ed fort Secti ofthe oCompensation,
as provltlatl for by Section 3700 o1 the Labor Code, for the performance of the work for which lNe
CYW
permit Is Issued.
[D I have and will maintain Workers Compensation Insurance, by Section 3700 C�
n^
�1!(
Seismic
as required of
the Labor Code, for the performance of the work for which this permit Is Issued. My Workers
^x s9
Uf' (v'urrl:/
i 77
Compensation InsuCraj carrierend Policy number are Iy' /
O/3I36
r7
TO
PERMIT AUTHORIZATION
DATE
Carder��JL��r� Policy No..�H
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p
(This section need not be completed It the permit Is for one hundred dollar. ($100) or lees.)
1 certify that in the performance of the work for which this permit Is Issued, I I not employ
any person in any manner so as to become subject to the Workers' mPon n Laws of can-
All roofs shall be in petted prior to any roofing material being
fornia.
Date 1— 6- y Applicant
installed. If a roof is installed without first obtaining an
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: 11, after me this Certificate of mptlon, you should become
subject to the Workers' Compensation provlslona of the Lebo tie, you must forthwith comply
PP ply with all non point
Applicant understands and will comply p
with such provisions or this permit shall be deeme. ravokedI
Source regulations.
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
All roof coverin sto be class' or better.
hereby authorize representatives of this city to enter upon the above- mentioned property (or In.
spection purposes.
indemnity keep harmless the City of Cupertino against liabilities,
•� �"
(We) agree to save, and
judgments, costs and expenses which may In any way accrue against said City in consequence
IGN UREOF (CANT -
of the granting of this permit.
DATE
PRE - INSPECTION:
PLYWOOD:
'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