00020027 (2) 2ebao6�
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBEFOkililM
INSPECTION DIVISION PERMIT E%PIRATION
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 �//
k G• a RESIDENTIAL COMMERCIAL OTHER
OWNER'S ,,/I //,�,, HAZARDOUS FIRE AREA
E]YES It yes—I understand that a Class A
NAME _/71I 1 l.(l roof assembly is required.
NO ❑ Initial I.C.B.O.a
ADDRESS �0 BerotaVfAn , 6fe. 101 y UYIOq14(e EXISTING ROOF COVERING
PHONE —,S NUMBER OF EXISTING COVERINGS '
CONTRACTOR'S
NAME ? ,051 f0r)nl k P g_n�j n9 TO BE REMOVED TO BE RETAINED
ADDRESSTYPE OF ROOF COVE
cITY s zIP �8 12- 5 P V i Yla St . (aMr Cl' EXISTING /
PHONE UP 91,0`1— 10151 BUILT-UP ROOF ��` Otto
LICENSE
NUMBER x32V l 1✓ ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Cade,and my license is in full force and
affect. ¢¢zp,e p� WOOD SHINGLES ❑
License Class VKTT tL l Lic.Number /J�
Date �• . loo Conbacmr 1,T—ESQ��r16yb P �b�t OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARA ION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason. /�\\ ,••,
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to a /
construct,altar,improve,demolish,or repair any structure,prior to its issuance,also requires the BU ILT-UPR OF ['I�
applicant for such permit to filo a signed statement that he is licensed pursuant to the provisions r'
of the Contractor's License Lew(Chapter 9(commencing with Section 7000)of Division 3 of the
Es
-
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT�HrINC3L ?' 10rG1
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to U (/U
a civil penalty of not more than live hundred dollars($500).): WOOD S AKES
L]1,as owner of the property,or my employees with wages as their sole compensation,will do Ify_ ❑
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Proles.
slops Code:The Contractors License Low does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employaes,provided that �_
such improvements are not intended or offered for sale.If,however,the building or improvement
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) Q P
not build or improve for purpose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sac,7044,Business and Professions Code:The Contractor's License Law does not PROVIDE LC.B.O. REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a comractods)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B 8 P.C.for this reason
Owner Dela APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION pQ Yy�/�
I hereby affirm under penalty of perjury one of the following declaration 2,AI /QV G I(�•x'aCx
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, / Building
as provided for by Section 3700 of the Labor Code,for the pedormanco of the work for which this
permit is issued. Seismic
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of JU/J�/ /'�
the Labor Code,for the Performance of the work for which this permit Is issued.My Worker's Total/ !_�
Compensation Insurance carrier and Policy number are:
Carrier L-�ra✓l ZY4�L1mnCPParayNa. WC3DtfJ72lD�1$ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed if 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 employ
any person in any manner so as to become subject to the Workers'Compensation Lows of call. All roofs shall be inspected prior to any roofing material being
forma. ,, Jit installed. If a roof is installed without first obtaining an
Date �•+•4/OG Applicantat2 inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Ce lcate of Exemption,you should coma Applicant understands and will I With all non Om}
subject to the Workers'Compensation provisions of the Labor Code,you must lorthwitn comply comply Y P
with such provisions or this permit shell 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 coverings to be class or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in. nnn
sp(We) purposes. C�i— _ 2/#/60
(We)agree s save,indemnity and keep harmless the City of Cupertino against liabilities, /
judgments,costs and expenses which may in any way accrue against said Clry in consequence SIGNAT RE OF APPLICANT DATE
of the granting of this permit.
�t 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY