R 6372L
OFFICE COPY
y "PERMIT R- '6372
APPLICATION FOR CITY OF CUPERTINO NUMBER .
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 ADDRESS �
n
2152-9 Tr_P_a. Oce 2x
RESIDENTIAL_ COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
`-
YES ❑ It yes - I understand that a Class A
NAME..
roof assembly is required.
NO - Initial I.C.B.O. #
• LOS - (•"��
ADDRESS I $ 8 9 G R 4fiae Q.. A J e. !] Y OZ
EXISTING ROOF COVERING
PHONE SO ^ Z
NUMBER OF EXISTING COVERINGS -
"
g
CONTRACTOR'S/J /]
Q���
NAME O—A n'), oyy-t-L2 !�-6!9'f..l'Av'/y
TO BE REMOVED TO.BE RETAINED
ADDRESS $J
TYPE OF ROOF COVERING
CITY & zip 2 2 9 L L I.Vr. r7 L.0 .4111 o S7,a
EXISTING
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PHONE - S/s — y�✓O O b �
BUILT-UP ROOF ❑
LICENSE
NUMBER SS9 3 6
❑ -
ASPHALT SHINGLES J
LICENSEDCONTRACTORS DECLARATION
hereby affirm that em licensed calif Section
under untler fessiprovisions of Chapter a it
.7000) of Division 3 of the Business antl.Proleselons Cotle, end my Ilce a Is In full lone and
WOOD SHAKES
enact. 5jrx0 J�3 / 9
WOOD SHINGLES ❑ y'
License Class Lid. Number
OTHER (SPECIFY) ❑
Date Contractor _
OWNER -BUILDER DECLARATION
I hereby that I from Contractors Lew for
GpROPOSED �L ff !]=x/ SQ
i 7
affirm am exempt the License th olll reason.
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
�o�
construct, alter, Improve, demolish, or repair any structure, p�rlpr.loAs•lss ffifice, also requires the
for
�JQ
- BUILT-UP ROOF ❑
applicant such permit to file a signed star pmant•thetriVT8 Ic nsetl ut nl to the provisions
of the Contractors License Law(Crept&T6(corl acing wit action I of Division 3 of the
Business and Professions Code) or -that he id axthere and basis for the alleged
exemption. Any violation o1 Section 7031.5 by'arly ee ant for a permit u to the applicant to
ASPHALT SHINGLES
a civil penalty of not more than five �u creel dollars ($500).$ p
❑ f, as owner of the property, dlr0y em Iola wl wgoesi QI so enhation, will do
the work, and the structure Is not Iglentle�roflaletl�tor %IeieL. 04 Inese and Profes-
WOOD SHAKES. ❑
sions Code: The Contractor's Lice pee LawQVs not apply to an owner o rty who builds or
Improves thereon, and who does e4tch work himself or through his own employ as, provided that
WOOD SHINGLES ❑ -
such improvements are not Intendoor offered for sale. If, however, the bulli in or Improvement
Is sold within one year of completion, the owner -builder will have have the bur oving that he did
OTHER (SPECIFY) ❑
not build or Improve for purpose of fill
❑ I, as owner of the property, antoxcluslYetycoMracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Code: The Contractors License Lew does not
_
PROVIDE I.C.B.O.. REPORT NO.
apply to an owner of property who builds of Improves thereon, and Who contracts for such projects
with a contractor(s) licensed pursuant to the Contractor's License Law.
1 am exempt under Sec. ,B & P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Data
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the fallowing federation:
❑ I have and will maintain a Certificate of Consent to soli -Insure for Workers Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
BUllding/
I.vsaee.
hese antl will melnlaln Workers Companeetlon Insurance, es requlratl by Section 3700 of
t or Code, for the performance of the work for which thio armJ( Is Iseu Worker's
ompensationaInsurance carrier and Policy number ere: yXf { 199
ZS
/
-
Seismic
Total l
J Lt re— F%%//%
PERMIT AUTHORIZATION
DATE
Carrier Policy No.
CERTIFICATE OF EXEMPTION FROM WORKERS'
/�
C
COMPENSATION INSURANCE N,C.C]
(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 Walk for which this permit Is Issued, I shell not empby
any person In any manner so as to become subject to the Workers' Compensation Laws of Cali-
All roofs shall be inspected prior to any roofing material being
fornia.
installed.. If a roof is installed without first obtaining an
Data Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, atter making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
Applicant understands and will cora
pP ply With all non point
with such provisions or this permit shall be deemed revoked.
source regulations.
I certify that I have rsad this application and stale 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 to verings to be cla r atter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We) agree to save, Indemnity and keep harmless the Clry of Cupertino against liabilities,
J,Z
judgments, costa and expenses which may In any way accrue against said City In consequence
of the granting of this permit.
3I U E OF APPLICANT DATE
PRE -INSPECTION:
PLYWOOD: ,
IN PROGRESS.
INSP. DATE
INSP. DAT
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