R 4977 (2) PERMIT R_ 4 9 7 7
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN IN DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
(��
J J `� -++�✓�'�`r N- RESIDENTIA6Z COMMERCIAL OTHER
OWNER'S ^ HAZARDOUS FIRE AREA
VES ❑ If yeas I und assembly
is req that. Class A
NAME c�Y�C�/V lXil_A) rrwf assembty is required.
c _ p - - _ N Initial I.C.B.O.#
ADDRESS ? CA �"�- EXISTING ROOF COVERING
PHONE
22=1, I NUMBER OF EXISTING COVERINGS 2
CONTRAC R'S
NAME ISS&I"3C4� r TO BE REMOVED TO BE RETAINED
ADDRESS n 2q � Q_` J TYPE OF ROOF COVERING
CITY&ZIP L 1 �"a�+
EXISTING
PHONE C�• n ^'� BUILT-UP ROOF ❑
LICENSE
NUMBER S-1 ' / ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby eIflmn that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES 1:17000)of Division 3 of the Business and Professions Coda,and my license Is In lull force and 4J
afla`t. (/ 9 3 WOOD SHINGLES .' ! ❑
License Cleea' `--�a-� U'.Numb
Date - _ -Li Contract OTHER(SP�ECyFI�� .7j ❑
f xs
OWNER-BUILD C RATION PROPOSED (✓N(, 6
1 hereby affirm that I am exempt from the Contractor's License Lew for the fallowing reason. (/
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to 'Cr
construct,alto,improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ,'y%V ❑
applicant for such permit to file a signed statement that he Is licen pursuant to the provisions
of the Contractor.License Law(Chapter S(commencing with Sec n 7000)of Division 3 01 the
• Business and Professions Code)or that he Is exempt therefrom tl the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applied tfora0 It subjects the applicant to
e civil penalty of not more than five hundred dollars($50 1r 1>
❑l,as owner of the property,or my employees With we as th ole compensation,will do WOOD SHAKES ❑
the work,and the structure IS not Intended o'l ad r a a 7 4,Business and Profes. '
alone Code:The Contractor's License La ae to et of property who builds or WOOD SHINGLES tPL
suchkea thereon,and who d0 such w IQQ�� II 1 mpg la own employees,provided that ❑
such Improve menta are
not completion,
leb n,th rsAl O..Or.the hulloing viImprovement
issoldbuild or
year of for purpose of
orb rwlll have the burden of proving that he die OTHER(SPECIFY)
not bulla or Improve for purpose of sole.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO. 3
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a c°ntractor(s)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
�t f
re
affirm under penalty of perjury one of the following suref rWo -
have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, irO Build
t pr vloed for by Section 3700 of the Labor Code,for the performance of the work for which Ihle 6�hJ✓
P le laeuetl. / Seismic
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Cotle,for the performance of the work for which this permit Is Issued.My Worker's
Compens n Ins encs c r end Polio number are: 2�f5Q Total
x Cerrier�
Policy No 1� 1111 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.]
(This section need not be completed if the permit le for one hundred dollar ($100)or less.)
I certify that In the performance of the wrork for which this permit Is asked. shell not employ
any parson 1 any manner so a.to become su a the War l a, 6naellon Lews m call- All roof.^•sl all be inspected pri to a y rod g Material being
f°`nla. installed. If a roof is installed without first obtaining an
oat. I — Applicant inspection,I agree to remove all new materials for inspection.
NOTICE O APP ICANT: If,after maki is Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provlelons or this permit.hal@be deemed revoked. Source regulations.
I certify that 1 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 buntline construction,and ring a lass"C"or better. 9/_
hereby authorize representatives of lois city to enter upon the above-mentioned property kr In. f 67
hereby
purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
judgment.,costa and expenses which may In any way accrue against said City In consequence
of the granting of this permit. SIGNATURE OF APPLICANT I DAT
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
r -
INSPDATE 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
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