R-3979 (2) PERMIT 3979
APPLICATION FOR CITY OF CUPERTINO NUMBERR.
PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 OT STARTED
WITHIN MIT Ego DAYS OF XPIRES IF PERM RK IS TISSUANCE OR
. IN DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS \ - BUILDING USE
100 -7-7 RESIDENTIAL COMMERCIAL OTHER
OWNER'S
/- _ � , f)5_1 C� _.,,, ,�L HAZARDOUS ROOF
NAME LS3-{YJ'�] Y V 1 V�`1�.V 61 AREA �� CLASS
COVERING
ADDRESS 1635 The -t'T10. ZZCI EXISTING ROOF COVERING
PHONE (J
C�Ci .�7 '�_. +Z"]� NUMBER OF EXISTING COVERINGS
CONTRACTOR'S j�
1t3-�I Yi7l - 110aTI 7W TYPE OF ROOF COVERING
TO BE REMOVED TO BE RETAINED
NAME
CC
AD \J
/ �fJ3 25b. EXISTING
PHONE— �g7 Z,j� BUILT-UP ROOF
LICENSESIC�� ASPHALT SHINGLES
NUMBER -�J
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
with S affirm 7000 I of Ilwns•tl under provisions ofd Chapter s(coons Code,
Cling with s«nen loom m Division a of m.Business and P,a+.seen.cad., WOOD SHING ES
and my unnw is In _u ce ma ettecL
Do,* Clm Lic.Number
Da. ai cane«tar '- o � OTHER (SPE IFY)
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt
n « from the Cony«70:a License Law for PROPOSED
the following •son. (S . 70]1.5. Business and Professions Coda: Any city
unto which requires a permit to construct, altar, improve,aerro ifn,o.
rugal,any structure,prior to its issuance,also requires the applicant for such BUILT-UP OOF
Permit to fila a signed statement that he is licensed pursuant to the provisions
of the Contractors License Lew (Chapter 9 (commencing with Section 7000)
of Division 3 of he Business and Professions Cone)or that he is exempt S ction ASPHAL SHINGLES
from and the basis for ftheor alleged rmi exemption. Any violation of Section
.1 no
by any that
no +ore permitsubjects).) me applicant to a civil penalty
of not mon twee five the pr tl erty, r y em WOOD S AKES
❑ I, ti own•r of ma property,o he employees with wages d man tole
Compensation(See. will do the work.Profane structureCode b not intended or offeree WOOD S NGLE
+ar ado(Sac. apps Bo an os and f property who The or Improves
m rove s License
Lew does
not apply \o an owner of property is o builds to imp,prof thereon,
and uc improvements
m ro e such work himselfint or edorthrough his own employees,provided that q
such ngo r improv are
not and within
ith o offered yea mr we. u, nothevo owner OTHER (SPECIFY) CGVrAV.�00C
building or bay. a bur i .ons wing to a year of completion,.1 me owner.
bursae.wiu nwa me ba.aen or proving that he ere nor mile or improve mr
pu,pas..f aale.). PROVIDE I.C.B.O. REPORT NO.
❑ 1, of owner or the property, am exclusively contracting with licensee
con\racton t0 construct \ne project (Sec. 7044, Business and Professions
Code: TheConnactVrsLicanfeLaw does not apply toanow of property PROVIDE III INSTALLATION SPECS.
who builds o improves thereon,and who contracts for such projects with a
cont rector0s)licensed pursuant to the Contractor's License Law.
❑ I am exempt under Sec. ,EL&P.C.for this
reason PPLICATION DATE VALUATION PERMIT FEE
Owner Dat. 8
WORKERS-COMPENSATION DECLARATION q Bu —8
I hereby affirm that 1 have a certificate of consent to .If insure.or a car. P g pa '1 � �s
tificate of Workers'Compensation Insurance.or a cvtili d opy thereof(S.C. G f./ (�NI f y 7� Seismic y`40
3800.Lab (ally-/'I J'4rc �N 'J ass
Policy No. Company i�J.y`�
t Bea copy Is hereby m.manea. q^ Total
❑ Certified Y;?Ii1��tn Mp city iNpaction dwifion.
Applicant \ / /� ALL
CERTIF CATE OF EXEMPTION FROM WORKERS' N C ❑ '� OF L'l ;,. PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE f
(Twit faction nootl not be completed if \M1e permit if for one hundred tlol.
lot($100)or I«s.l
I certify ih me\ in ma performance of the work for anion this permit if
issued,the Snell not employ any Lenon any manner so a to become subl«t
\o the Workeri Compensation Laws of Calif orni•.n
Data Applicant
NOTICE should
APPLICANT: o anet making anis Compensation
of Exemption.
Voss sM1ould D«oma wDl«[ to ma Workers'Companw[ion provisions of ma
Labor coda, you most forthwith comply with such provisions or this permit All roofsshall be inspected prior to any roofing material being
shall be doomed revoked.
1 certify th« I In...read mit application and ante that me so..otorma Installed. If a roof Is installed without first obtaining an
nonis correct, I agree to comply with all city and county ordinances dna inspection,I agree to remove all new materials for Inspection.
state laws relating to building construction. and hereby authorize r•pr«•m
tetives of this city to enter upon the abovementioned property for inspection
(We) •gree to uv, indemnify and keep harmless \M1• City of Cupertino �o�jUf 7
against I abuiei«.judgments,costa and expanses wh ic0 may in any way•acus
against said City in consequence of the granting of thispermit. SI ATURE OF APPLICANT DATE�—
PRE-INSPECTION: PLYWOOD: III 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 .