R 4720 (2) PERMIT
R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 472'07
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
X533 p, oQ�f BoArJ
RESIDENTIAL COMMERCIAL OTHER—
OWNERS
THER
OWNER•s/�/\ AZA❑iDOUS FIRE AREA
NAME 1 i I�r �f�'�Q S �i�� ii YES ❑ If
assembly is requirend that d. Class A
+� NO Initial I.C.B.O.#
ADDRESS5�3 QdA 17 EXISTING ROOF COVERING
PHONE OH ZSS-r0 Z`/ NUMBER OF EXISTING COVERINGS 6A f—
CONTRALTO S �QUr l M TO BE REMOVED nr ll✓ TO BE RETAINED
ADDRESSc TY a ZIP �� �� 611Ulsl q � Cv�vt TYPE OF ROOF COVERING
G� EXISTING
PHONE– U0l �� —222-!7 BUILT-UP ROOF ❑
LICENSE
NUMBERASPHALT SHINGLES ❑
LICEN ED CONTRACTORS DECLARATION
hereby affirm that I em licensed under provisions of Chapter 9(commencingwith Section WOOD SHAKES
IsIn
7000)of Division 3 0l the Business and Professions Code,and my license la In full force and
effect.
�
License Class Lic.Number T WOOD SHINGLES P AID-El
Date 9 Conti eaor OTHER(SPECIFY) p
OWNER-the Conn DE rs Lice se PROPOSED JAN 17 1996
I hereby affirm Bu that am exempt from the Contractor's License Law fort to owing reason.
(Sec.7031.5,Business and Professions Coda: Any city or county which r of a a permit to
construct,after.improve,demolish,or repair any structure,prior to Its lssuaoc at orequires the BUILT-UP ROOPITY
applicant for such permit to Isle a signed statement that he is licensed pursuan t the provisions + Ur l,l)rc l'1 I Oil /
of the Contractors License Law(Chapter 9(commencing with Section 70)o v"It,
sion 3 of the
Business and Professions Code)or that he is exempt therefro and I "Italleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a rpik gap cantto
a civil penalty of not more than five hundred dollars($500).):
El 1.as owner of he property,or my employee waped_a r n, Illdo WOOD SHAKES Elthe work,and the structure Is not Intended ar arelrfol'; 04 Business an rotes.
sions Code:The Contractor's License Law it s no IF o serol property who builds or WOOD SHINGLES
improves thereon,and who does such work hl hr pb his own employees,provided that ❑
such improvements are not intended or offere9 a)0.-R;however,the building or Improvement
is sold within one year of completion,the owner- i or have he burden of proving that he did OTHER(SPECIFY) ❑
not build or improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractions)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B 8 P.C.for this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit isS�•� ,S'elsmi
❑ have and will the pert Worker's Compensation the work
for Insurance,as required Is
by Section 3700 of
the Labor Cotle,for the performance of cy ware for which this permit la Issued.My Worker's Total
Compensation Insurance terrier and Policy number are:
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.D `^
(This section need not be completed if the permit is for one hundred dollars($100)or less.) I
I certify that in the performance of the work for which this permits issued,I shall 1 employ
any person in any manner so as to become subject to the Worker ompensetlon of calf All roofs shat a inspected prior to any roofing material being
forma. _ 9 installed. If a roof is installed without first obtaining an
Dale Applicant % inspection,I agree to remove all new materials for inspection.
cate OExeflon. ou should become
subject IONOT CEhe Wo Workers'CompefnsatPLICANT&. I. l n provisionis of the ths tLabor Codemyau must forthwith Comply Applicant understands and will comply with all non point
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.
spa e)purposes.
(We)agree tos save,indemnify and keep harmless cc Clry of Cupertino y Inagainst liabilities,
ence
• of the gran costs and expenses which may In any way accrue against said City In consequence
o the granting of his permit. 5rGNATURE FAPPLICANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
f 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
OFFIr r rnPV