R 5998 PERMIT R_ 5 9 9 8
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
BUILDING ADDRESS
180 DAYS FROM LAST CALLED INSPECTION.
a �k
I LU' Opt DENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME Ars Q V y- root assembly is required.
NO ❑. Initial I.C.B.O.a
ADDRESS 13 OW Ri C h ijok d S n Afav , EXISTING ROOF COVERING
PHONE SO- 6 ii NUMBER OF EXISTING COVERINGS
CONTRACTO`R'S
NAME J O 1,r h TO BE REMOVED TO BE RETAINED
CITYRBZP :73ADDESS TYPE ROOF COVERI
$1 lG+yiEw IPA' • /p6//is"ie r.4. F
Sr�0 j EXISTING
PHONE /- 54* - 6 30 - 3 338 BUILT-UP ROOFLICENSE
❑
NUMBER 6 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 em licensed untler provisions of Chapter g(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect. WOOD SHINGLES ❑
License Class C'3p-CNS LIc.Number 6/Zlz3
Data LJol�n da OTHER(SPECIFY) ❑
_
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm Business net 1 em exempt from the e: Anytor'e License Lew for the following rmit t.
(Sec.7ct,alt ,Improvand Professions it Code: Any city or county which re,also a permit to
construct,eller,Improve,demolish,or repeat any structure,prior to Its Issuance,°lath reproves the BUILT-UP ROOF ❑
ttheapplicant for such permit License lila a signed statement that g it I Soctl d p 000,ortth Ins pro 0,the
• of the ss and lPre ssions Lew(Chapter a(commencing with therefrom
and 7000)of for the 3 of the
ex a exemption.
entl Professions of Code)or that he Is exempt ant for
end the baste far the alleged ASPHALT SHINGLES
exemption.Any violation of Section hundred
by any applicant for a permit aubjecta the applicant to
e civil penalty of not more than live huntlretl dollars($500)J: ❑
01,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ^
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profen a V
Sion Coda:The Contractor's License Law does not apply to an owner at property who builds or WOOD SHINGLES ❑_
Improves thereon,and who does such work himself or through his own employees,provided that rD
such Improvements are not intended or offered for edea.ill however,the en of r or ImprovementIs �� £
not
ld build rImpryone e tar
of saleownenbulltlerwill have the burden of proving that hedid OTHER (SPECIFY) i, C
not bulM or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct I ItxJ
the project(Sec.7044,Business and Professions Code:The Contractor's License Lew does not PROVIDE I.C.B.O.REPORT Nye:C
apply to an owner of property who builds or onroves thereon,and who contracts for such projects GIIT W
with a contractor(a)licensedprrsuant to the Contractor's License Law. PROVIDE fill INSTALLATION SPECS.
IYLam exempt untr Ste. ,8 8 P.C.for this reason
Own / ]1
Date —
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: [7
❑ have and will maintain a Certificate of Consent to self-insure performa for Worker's Compensation,this 1 / q 'y /� Ili O Building IS-71 �a
pe mit is Is for by Section 3700 o1 the Labor Code,for the performance of the work Mr which ihle �t� JMz 1 C
permit isle and '1700 of // / Seismic . i
41
❑1 have and will maithe pert Worker's Compensation the" tfor Insurwhich ce,this as permit Is Is by Section Worker's /
the Labor Code,for ins performance of the work for which This permit la Issued.My Worker's
Compensation Insurance carrier entl Policy number are: Total Q
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.] 9
(This section need not be completed If the permit Is for one hundred dollars($100)or lase.)
I certify that In the performance of the work for which this permit Is Issued I shall not employ o
any person In any manner so as to became subject to the Workers'C°mp°nsatin Laws of Cali. All roofs shall be inspected prior to any roofing material being
installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE Subject to theOWorrkers'C°mpef,after nsdti nproivisionsofetheflcate Labor Codef°you must °forthwldbecome
th comply Applicant understands and will comply with all non point
with such provisions or this permit shall be doomed revoked. source regulatiom.
I certify that I have read this application and state that the above Information is correct.l agree
to comply with all city and county ordinances and elate laws relating to building construction.and All roof CO rl t0 be BE; Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposesb qy
(We)°gree to save,Indemnify and keep harmless the City o/Cupertino against Ilabllltlea, ^ ✓,1'(, �•-�S' !O
judgments,costs entl expenses which may In any way accrue against said City In Consequence
• of the granting of this permit. SI ATURE OF APPLIC NT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION .
OFFICE COPY