R 6094 (2) PERMIT R_
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 I
21825 ./fYan�r�IsPaYt� �rz�vE
• RESIDENTIAL � COMMERCIAL OTHER
-OWNER'S HAZARDOUS FIRE AREA
Cb CY �.J OLIQ .ZxCUlnl VES ❑ 111=s fumy is retlthad. Class
NAME roof assembly 15 required.
' NO ❑ Initial LC.B.O.p
ADDRESS 21$7-5 1+'Yl4'N 19POA bit. VEERING
PHONE — 5 l NUMBER OF EXISTING COVERINGS 0) A&b ghl'A%L
CONTRACTOR'S
NAME
�f14)E e / TO BE REMOVED I TO BE RETAINED
ADDRESS / MM TT TYPE OF ROOF COVERING
CITY&ZIP 35z f+illi AioZf-?UI cS.J 951 .
EXISTING
PHONE OP ZZ9 — CrIS9BUILT-UP ROOF
LICENSE
NUMBER I ZK* ASPHALT SHINGLES - ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 8(commencing with Sec 00' WOOD SHAKES
7000)of Division 3 of the Business entl Professions Code,and my license le In full force and
effect. WOOD SHINGLES
License Cleve
e 3() 3, r$� ❑
UC.Number
Date
8-04_9 � Contractor 'Dates &V(d LJA) OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that I em exempt from the Contractors License Lew for the following reason.
(Sec.7a3 S.Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,demollah,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
• of the Contractors license Lew(Chapter a(commencing with Section 7000)at Division 3 at the
Business and Professions Code)or that he Is exempt therefro and Me basis for the skinned ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for ipermit subje applicant
e civil penalty of not more than five hundred dollars($500).): I(�I
❑I,as owner of the property,or my employees with wages of t sole pen n,wIIIkU WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale( rbu
44,Business and Proles.
Impalone C�e:reo,anwhod License workhiself apply r through hofgroperty PhpO,�ulltle aL� WOOD SHINGLES ❑
Improves thereon,entl who dose such work himself or throughe e, ro e
such improvements are not Intended or offered for sale.If,hewse bXA or Ira epMW
is sold within one year of completion,the owner-builder will have roan of proving that he did OTHER(SPECIFY) El
build or Improve for purpose of Bele.).
❑I,as owner of the property,em exclusively contracting with c sed conirectore to construct
the project(Sec.7044,Business and Professions Code:The C t r'e Llonee Law dose not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,en
with a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.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:
C] /� /..S
I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this A
permit is leeuetl. �— l(/ Oo seismic , 12-0
❑I 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
Compensation Insurance carrier and Policy number are: Total
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If the permit Is for one hundred dollars($100)or 1085.) T o 7
I cenity that In the performance of the work for which this permit Is Issued I shed not emptoy
any person In any manner so as to become subject to the Workers'Compensallon Lewy at Cali- All roofs shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Date `I-OLI-99 Appncam -1 A Je— (1 W&M-s.iA) inspection,I agree to remove all new materials for inspection.
ome
subject 2the WE TO mkers'C mpo�aaio provisions of thefiLaborr Code,cate of Exemption,
mustuforthwlitth comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. 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 ro f coverings to be class- bitter.
hereby authorize representatives of this city to enter upon the above-memlened property for In-
selection purposes. t
(We)agree to save,Indemnify and keep harmless the City of Cupertino against Ilebllitles,
ludgmenta,coats and expenses which may In any way accrue against said City In consequence
• of the granting of this permit. IT 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY