R 6098 (2) PERMIT R_ 6098
.
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 /� r/� 2 1N1' (�
IDI O+ I I�/ I ✓V 1 I I.I I�/�/ AdL7
RESIDENTIAL— •COMMERCIAL OTHER
OWNER'S F T /� HAZARDOUS FIRE AREA
NAME aMw 1 hOH77 ` �, YES ❑ It
understand
is
that a ClassA ,
assembly required.
, ' NO ❑ Initial I.C.B.O.W
ADDRESS- 99D L F-Vy EL Q V IE, fro[✓E EXISTING ROOF COVERING
PHONE I —rR�D I:J21 NUMBER OF EXISTING COVERINGS DI'49
CONTNAME CTO$$a L CL tq SSOC 1 H-fe,S TO BE REMOVED�TO BE RETAINED
NAME CC��-jljl C
ADDRESS '
TYPE OF ROOF COVERING
CITY 8 ZIP A AS' � �� Jf nlT� EXISTING
PHONE }o g z 6 z ZS-714
--7,f BUILT-UP ROOF ❑
NUMBER /`1 ZO3 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION x,
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
License CI ea C3g Lic.Number WOOD SHINGLES El
•
Date � 1 7_q El Contractors OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby ellirm that I am exempt from the Contractors License Law for the following reason. X.
(Sec.7031.5 Business and Professions Code: Any city or county which requires a permit to `J
construct,site mprovaitlemoliah,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF
applicant for suc
limit
file a slgned statement that he Is licensed pursuant t he provisions
of the Contracture ansa Law(Chapter 9(commencing with Section 7000 Mill 3 of the
• Business and Profess Cotle)or that he is exempt therefrom and t seta for the alleged ASPHALT SHINGLES F IJP
exemption.Any violation a tion 7031.5 by any applicant for a permltsubjects the applicant to 6 -
a civil penalty of not more then h`undred dollars($500).1:
❑1,as owner of the Property,or' ertlployeea with wagesafheir sole comportEndPmfes-
slons
AKES ❑
the work,and the structure Is not Intends Affered,lorsele(Sec.7044,Business-slF s Cotle:The Contractor's License Law doee,m(apply to an owner of propertyorWOOD SFiI GLESIm roves thereon,entl who does such work hl all o7Mr ugh his own employees, atsuch Improvements are not Intended 0�ered Ior Sale,i6ever,the building orntIs sold within one year of comptetiorNhe owll have burden of prov6if T MR( ECIFY) ❑not build or Improve for purposed sale.). OV4 ZJI,as owner of the prypdty,am exclusively contracting with licensed contractoctthe project(SSC.704 f8u-'neseandProfessions Cotle:The Contractors LicenseoL PROVI C.B.O.REPORT NO.
apply to an owns property who build,or improves thereon,and who contract.fortl iwhhaconi' r(s)licensed pursuant to the COnireclore license Lew. fLll �OVI FGR.INSTALLATION SPECS.
❑le exempt under Sec. BBP.C.t
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 malnuon a Certificate of Consent to self-insure for Workers Compensation, ^ Building/as provided for by Section 3700 of the Labor Code,lot the performance of the work for which this (� �Ot✓ g/Z-7
per d Issued. a 7 —9 71 Seismic 8O
per
and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit Is issued.My Worker's
Compenset n neurprnncce ar `antlP 11 ynumber are: /�/��� 7 Total /27, 46
Canlar 7�L��/i-- V/W(/ PanCV No. PERMIT AUTHORIZATION DATE
CERT4EICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N,CQ
(This section need not be comp e(,ed If the permit is for one hundred dollars($100)or lees.)
I certify that In the performance of ihs,work for which this permit is Issued,I shall not employ
any person In any manner so as to became subject to t or era Compense rr Law-of Co". All roofs shall be inspected prior to any roofing material being
to'n'e. "�`\ installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: II,after making this ce Icate of Exemption;yop should become
subject to the Workers'Compensation provieJJoohe of the Labor Code,you must folNwith comply Applicant understands and will comply with all non point
with such provisions or this permit shall-sato.mod revoked. - source regulations.
I certify that l have read this application and state that the above Information is correct.l agree
to comply with all city and Rfy ordinances and state law.relating to building Construction,and A oof coverings to bM-22)C"or better.
hereby authorise re nlelives of this city to enter upon the above-mentioned property Mr in.
sP ction we),purp U/y/1.5� �7r(We), res to save,Indemnity end keep hermlass the Clty at Cupertino against Ilebllltlea, `7
judgments,cost-and expenses which may In any way accrue against said City In consequence
of me granting of this permit. SfG'I�ATURE 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 -