R 5766 (2) APPLICATION FOR CITY OF CUPERTINO NUMBER R- 57 6 6
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1e0 DAYS OF PERMIT ISSUANCE OR
160 DAYS FROM LAST CALLED INSPECTION.
BUILDIN//G ADDRESS /� �,Ir, .
1 Q bU ' Al•'O I R l� ., 7v U- RESIDENTIAL- COMMERCIAL OTHER
OWNER'S ^ HAZARDOUS FIRE AREA
/J� / L&L YES ElIt yes-I understand that a Class A
NAME �l roof assembly is required.
/�y
NO E] Initial I.C.B.O.p
ADDRESS-4-60 VL— EXISTING ROOF COVERING
PHONE `T /b — go OIL-, NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S ^` �
NAME AJ 7_46&Z4 /W 0 ( L-K--y TO BE REMOVED TO BE RETAINED
ADDRESS 86 1 2466Y 114 JW L gr) - TYPE OF ROOF COVERING
CITY 8 ZIP
4N ^/� �l�_J- EXISTING
PHONE t7 7 BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under prwislons of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is in full torte and
enact. C ,31
3 9 9�6 /s� WOOD SHINGLES ❑
License Class Lic.Number
Date /V —1j."9d' Contractor G1/L/h ��.Crl LQ/l� OTHER(SPECIFY) El
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sac.7031.5,Business and Professions Code: Any city or County which requires a permit to
construct,alter,Improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF Elapplicant for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Cotle)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).):
❑I,as owner of the property,or my employees wit ecompen�a{Ion,wl WOOD SHAKES ❑
the work,and the structure is not Intended or offered ale(Bec. Business dnd Pro
alone Code:The Contractor's License Law does no a I an party iJlo build o WOOD SHINGLES ❑ b��
Improves thereon,and who does such work himself or h his n employees,provided a
such Improvements are not intended or offered for sal wever,the bulldln or img[g1(am nt
Is sold within one year of completion,the pwrit bulltler i ve seal IIIAINa Itl Inllnt l�:,r�+ l�•L
not build or improve for purpose of sale.). ��� p V IJJV OTHER(SPECIFY) ]
❑I,as owner of the property,am exclusively con with licensed contractors to constr �D
the project(Sac.7064,Business and Professions Cod a Contractors License law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or improves the n,and who Contracts for such projects
with a contmctor(s)licensed pursuant to the Contracto ense Law.
❑I am exempt under SecPROVIDE MFGR.INSTALLATION SPECS.
. n
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: r�
❑I have and will maintain a Certificate of Consent to sell-insure for Workers Compensation, BGI din
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this / g /
p Is issued. ( D. r1- dj Seismic LO
have and will maintain Worker's Compensation Insurance,as required by Section 3700 of t j 7 /
the L bor Code,for the performance of the work for which this permit is issued.My Worker's / r ZQ
Compen-scation Insurance carrier an tl Polic umbar era: 9 Total
camlera�� Z14 ' Policy No.0/06(D2-T1/ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(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 became subject to me Workers'Compensation Laws of Can- All roofs shall be inspected prior to any roofing material being
faints. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOT CE TO APPLICANT-. shoul
subject t.the Workers'Compelnsati n provisionls of theflcate Labor Code yolu of onmustafo thwithcecome 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 slate that the above Information is correct.I agree
to comply with all city and ounty ordinances and state laws relation to building construction,and All roof OVerin s c ass"C„Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In. -
g e p 9
epectienpurposes. r I �M /D ,17. �J
(We)agree s save,indemnify and keep harmless the City of Cupertino against liabilities, C/`JAI,) I OAU 0
judgments,costs and expenses which may In any way accrue against said Clry In• oneaquence SIGNATURE OF Aql the granting of this permit. 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