R 5461 (2) PERMIT _
CITY OFCUPERTINO NUMBER , 5461
INSPECTION DIVISION PERMIT EXPIRATION
"._ 41MIT (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
ree
1iD333 POJDv
RESIDENTIAL COMMERCIAL OTHER
OWNERS x /�� ���[/ HAZARDOUS FIRE AREA
NAME; l & f & v� w 17�Lr I"s, YES ❑ roo assembly is requand ihred.at ClassA
2 2 1 n NO Q Initial I.C.B.O.H
ADDRESS (0333 PQJZ U(s-� 12,0CL_D1 EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONT CTOR'S
kAA
70 BE REMOVED TO BE RETAINED
NAME Q
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE (�O IQs' Yl"4b BUILT-UP•ROOF ❑
LICENSE
NUMBER 99 J' ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES
7000)of Divlslon 3 of the Business and Professions Code,and my license is In full force and /
effect. n WOOD SHINGLES ❑ `��
License Class l- ?2y Llc.Number
Date /
IIS9� Contractor/ OTHER(SPECIFY) El
`_
OWNER the Confi DECLARATION PROPOSED '
hereby affirm.Business
em exempt from the e: Any ois or coua Lew for the follow ng reason.
-(Sec:construct,
It BImprove and Pros,or rep Code: Any city or coon
applicant,alter,h prove,to file demolish,g ed staairtement
anystructure,Is Iceor o Itjusun�acbieureete UILT-UP ROOF ❑applicant for ouch permit to ILIe a elgned statement that he Ish Sect 00)oft t vlsloneof the ss an dPra License Law(Chapter h(commencingwlm Seca00)ofiBusiness end violation of Cotle)or that he Ia exampt antfora e DaSPHALT SHINGLESexemption.Any ltyof othno of Sect ion 7031.5 anyappllcantfore pabject- edull,as ow al notmorethanfive byempl dollyeesreth wag.):❑Las lid the sth cture I not I tended oyeaered wages as(SecleBust OOD SHAKESthe work,entl the structure le not Intentletl or olferatl Mr Bele(Sac. 4,Busisions Coda:The Contractor's License Law does not apply to en owf property who bulltle or OODSHINGLES n
Improves there ❑
1-raon,and who does such work himself or through his o n mployaea,providetl that
such Improvements are not intended or offered ler fare,if,however, h Ilding or Ira rovement
Is sold within one year of completion,the owner-builder will have the TH ER(SPECIFY)
not build or Improve for purpose of sale.).
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct Q
the project(Sec.7044,Business and Professions Code:The Contractor's License taw does not PROVIDE I.C.B.O. REPORT NO. —221 D 1
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Lew. PROVIDE MFG,.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to solf-Insure for Workers Compensation, BUlldl4 7•
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
perm is ad
_�/ (�p Q Seismic SQ
have and will malnteln Workers Compensation Insurance,e9 required by Section 3700 of
t Labor Code,for the performance of the work for which this permit Is Issued.My Worker's
mpena o Insurance carnntl PoII'cy number are:
^��,, Total I So
camert - [�Jl_ PolicyNo.�91U_tj / PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C❑ A_/y'`O 8
(This section need not be completed It the permit Is for one hundred dollars($100)or less.) L 2
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of Call- All roof^shall be inspected prior to any roofing material being
fornia. 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: If,after making this Certificate of Exemption,you should become applicant understands and will Comply with all non
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply p Y point
with such provisions or this permit shaltbe deemed 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 county ordinances and state sews relating to building construction,and All ro verings a Sa' "or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spiff purposes.
(Wry ^y
- (We)agree to save,Indemnity and keep harmless the Clry of Cupertino against liabilities, 6 JY�f•+l
judgments,costs and expenses which may In any way accrue against said City In consequence
of the granting of this permit. SI UR F A PL N DAIE
�E-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