R-4920 PERMIT R_ 492
0
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
Amok 100 DAYS FROM LAST CALLED INSPECTION.
BUIL/DING ADDRESS /�•� ^�
/Z? RESIDENTIAL COMMERCIAL OTHER
OWNER'S / -//� yN� HAZARDOUS FIRE AREA
NAME rL 1/N "r al' / YES ❑ If Iunderstandthea. Class
roof s—I un ty is required.
S / / NO Initial I.C.B.O.If
ADDRESS ��r-,) 3 2 `' �����%� "`� EXISTING ROOF COVERING
PHONE Z 3 NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
NAME
��� /S"� �� TO BE REMOVED. TO BE RETAINED
�f G/"`
ADDRESS g— � Z j _�� TYPE OF ROOF COVERING -
CITY&ZIP �^! EXISTING
PHONE — 6 BUILT-UP ROOF ❑
LICENSE
;:
NUMBER ✓ bAASPHALT SHINGLES ElLIC NSED CONTRACTORS DECLARATION �
1 hereby affirm that I am licensed under provisions of Chapter g(commencing gT WOOD SHAKES 31C7000)of Division 3 of the Business and Professions Cotle,and my license Is In fu or. a
effect.
�. WOOD SHINGLES ❑
License Class n Uc.Number
S�.-7 ��YG OTHER(SPECIFY) [Ellr,
Date �r Contractor
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm Bu Ines em exempt from the e:Contractor'scity orLicenseoup Lew for the folrequires
a reason. MAY Y 2 9 1996
(Sec.70315,r,improve,
and demolish,
or rep Code: Any city or county which requires a permit to 1r'f1 IJJ
applicant
altar,Improve,to file signed
nrepeatenystructure,prior to Its Issuance,puruant also requires the BUILT-UP ROOF ❑
of Ile
Conor etch permit to flaw a signed atetem m that he is licensedSection
pursuant the provisions
• of the Contractor's License Lew(Chapter h Is ex'commencing t with Section 7000)of Dlvialhe 3 0l the v'I I r VI t,✓Ou r I uaV
exemption.
and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLE
$
exemption.Any violation of healon 7031.5 by any applicant for a permit subjects the applicant to
hundr
e civil penalty of not more than five hundred employees
dollars(h wager WOOD SHAKES
❑I,k, owner o1the property.or to employeesredh reale as their sola compensation,wolf s.
the work,and the structure is not Intended hi self o for through
(Sec.7044,employees,
and Pmtea-
alone Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES
❑
Improves thereon,and who does such workhimselffor
or through hie own employees,provided that (p
such Improvements are not Intended or owner-builder
far dear.If,however,the buildingof pr or Improvement ( V
Is notsold bull or
prove for purpose
stee owner-bulltlerwlll have ane burden of proving that he dltl OTHER(SPECIFY)
not build as
Improvehe purpose of eels.).
I,as owner of the propBrumesrty and Professions Code:
T with Contractor's
Licicensed ense
Contractors to construct
not
the prolan(Sae. of property
h end Profr Improv Cotle:The Contractor's License Lew does not PROVIDE LC.B.O.REPORT NO.
apply to c ntownerof property who bulltls or Ie Contrathereon,end who contracts for such projects
with a contractors)licensednrSe pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,BSP.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
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, Building
as provided for by Sectlon 3700 of the labor Code,for the performance of the work for which this
1,permit laIssued. /�zq 1(6 )2-606r Seismic
•� ❑I Is s end will maintain Worker's Compensation Insurance,as required by Section 370001 ✓\
the Labor Code f the performance of the work for which this permit la Issued.My Worker's Total
Compensation r e trier and Policy number are: a/41C_30;fOU-
caller FON RO No. PERMIT AUTHORIZATION DA E
CERTIFICATEOFCOMPENSATION
SURANMWORKERS'
COMPENSATION INSURANCE N.C.]
(This section need not be completed if the permit Is for one hundred dollars S1 00)or less.)
I certify that In the performance of thework for this permit Is Issued,I shall not employ
any person In any manner so as to become au to th wot rata'Compensation Laws of Call. All roots shall be inspected prior toy roofing mate i 1 e1 g
fornix. C installed. If a roof is installed v hout first obt Hing an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE subject to therrAPPLICANT:' pens Iron proviafter sions oftheiLa o Code,you must forthwid become
th comply Applicant understands and will comply with all non point
with such provisions or this permit shell be seamen revoke . SOL! 1ations. -
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 ormnancad and state laws relating to bullding construction,and A roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes. OJV
i z
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, r''
judgments,costs and expenses which may In any way accrue against said City In consequence SIGNATURE'O PPLICA DATE
of the granting of this Permit. '
PRE-INSPECTION: PLYWOOD: I -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