R 5162 (2) PERMIT R_ 516 2
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
say 74 � taw - . cam ,
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
_ YES ❑ If yes-1 understand that a Class A
NAME l_7 QA'f roof assembly is required.
NO Initial I.C.B.O.k
ADDRESS �7— EXISTING ROOF COVERING
PHONE '7 'S 2� NUMBER OF EXISTING COVERINGS
CONTRAC
C� TO BE REMOVED TO BE RETAINED
NAME _
Z qS� TYPE OF ROOF COVERING
ADDRESS nQZ /RM /� ^ . - �+�^ Q o-�d4-
CITY 8 ZIP ov/ / C.6-1�i1... LJ(MR,. J
EXISTING
PHONE 4°18 '0 6 r/ 7 BUILT-UP ROOFLICENSE ❑
NUMBER `-) 9 ASPHALT SF LEPAID
❑
LICENSED CONTRACTORS DECLARATION 1 c
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAK '+ t/ 1(tl �Q
7000 of Division 3 of the Business and Professions Code,and my license Is In full force and /S r"
1 G 7 / L� .
Liaise Cl esa �3 Lia Number ' / / b WOOD SHI GL�S•.(/r.Cn,f/yU ❑
Date �O �S Contractor 7 . OTHER (SPECIFY) ❑
OWNER-BUILDER DECLARATION
I hereby affirm that I em exempt from the Contractors License Lew for thaffollowing reason. PROPOSED T J
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to Ili
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF B v ❑ ��
applicant for such permit to Ilse a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Lew(Chapter g(commencing with Section 7000)of Division 3 of the �(,
• Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHAL IIV J 3�
❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to jgA ,t
e civil penalty of not more than five hundred dollars($500).): 06' I u
❑I,as owner of the property,or my employees with wages as their sole compensation,will doW0Fti�lh' w-A-di 8
the work,and the structure Is not Intended or offered for agile(Sec.7044,Business and Proles.
sions Code:The Contractors License Law does not apply to on owner of property who builds or WOOD SHINGLES u
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not intended or offered for sale.If,however,the building or improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew does not PROVIDE I.C.B.O. REPORT NOF
apply to an owner of property who builds or improves thereon,and who contracts for such projects /
wuhaconilicensed pursuant m
to e Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
C] exempt I em exempt under Sec. ,B 8 P.C.for This reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
1 hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, opBuilding
permit Is Is for by Section 3700 of the Labor Code,for the performance of the work for which rale /O//5/�� �^ ^/],)
permit Is have
and ✓/t/ )V(v v Seismic
❑I have and will themaintain Worker's Compensation the workfor Insurance,as requireditsissued,
Section 3700'of s
the Labor Code,for the performance of the work for whish this permit le leauatl.My Worker's
Compensation hjeure�nc-e cerrler en'd Povlley number ora: Total
cerrler I, �r ^�,� Polmy No.-A317"? .76?2v PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
s COMPENSATION INSURANCE N.C.O D
(This section need not be completed It the permit Is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit Is issued,I shall not emlay
any person In any manner so as to become subject to the Workers'Compensation Laws of Lea- All roofs shall be nsp cted prior to any roofing material being
fornoa. installed. If a root is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE APPLICANT: If, ou should
subject to theOWorkers'Compensatlorn provrisionis ofethefl
Labor Coca,cate you of mustfothwithbecome 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 roof CO girl B tO ID Cl SS"C"Or better
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes. ' /O
(Wal agree to save,Indemnify and keep harmless the City of Cupetino against IlabilltieB, rj .�
judgmente,coats and expenses which may In any way accrue against said City In consequence
• of the granting of this permit. SIGNATUR&OF APPLICANT 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