R 4854 (2)10
11
OFFICE COPY
PERMIT R- 485514
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
�7 � s'G �17i•4C.
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
S
�C-7Q
YES E]If yes - I understand that a Class A
NAME�f/� o /.[//.�� «
roof assembly is required.
NO ❑ Initial I.C.B.O. a
oS"
n
ADDRESS- yam' /s%bN-r (.-�2e�'�-
EXISTING ROOF COVERING
PHONEr-O 4
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
,r/,z..,� /
NAME �%a 'Y
TO BE REMOVED TO BE RETAINED
ADDRESS ^'�� �y�
TYPE OF ROOF COVERING
CITY 6 ZIP
EXISTING
AVf_2-1P1,1 ^
PHONE f=D�
BUILT-UP ROOF ❑
CENSE
NIUM13ER
ASPHALT SHINGLES ❑
L CENSED CONTRACTORS DECLARATION
Iheresy affirm that I em licensed under provisions of Chapter a (commencing with Section
WOOD SHAKES 13
700of Division 3 of the Business and Professions Code, and my license Is in full force and
effect.
e-5 z!ef
WOOD SHINGLES ❑
License C sea LIc. Number
10,54
OTHER (SPECIFY) ❑
Date Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I em exempt from the Contractor's License Law for the following reason.
PROPOSED
(Sec. 7031.5, Business end Professions Code; Any city or county which requires a permit to
construct, alter, Improve, demolish, or repair any structure, prior to lte uance, also requires the
BUILT UP ROOF ❑
applicant for such permit to file a signed statement Inel he Ie if.anee uant to the provisions
of the Contractor's License Lew (Chapter g (commencln with Section of Division 3 0l the
Business and Professions Code) that he Is t
or exempt arabdm and t for the alleged
ASPHALT SHINGLES ❑
exemption. Any violation of Section 7031.5 by any epplicant,ler ar a the applicant to
e civil penalty of not more than five hundred dollars (350qq)p:
❑I, as owner of the property, or my ampfoyeeewun yl to ecompensetion, will do
WOOD SHAKES ❑
the work, and the structure Is not Intended c offered,for s Ie ( 7044, Business and Profile.
alone Code: The Contractor's License Law does not ply nor of property who builds or
Improves (hereon, and who does such work r t u
hlmsel is own employees, provided that
WOOD SHINGLES ❑
such Improvements are not Intended or offered for'%V. II, waver, the building or Improvement
Is sold within one year of completion, the owner -bull 11 have the burden of proving that he did
SPECIFY
OTHER (SPECIFY) ❑
not build or Improve for purpose of sale.), t
❑ 1, as owner of the property, em exclusively cor trecllnG with licensed contractors to construct
the project (Sec. 7044, Business and Profeeeions Code: The Contractor's License Lew does not
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who bunds or Improves thereon, and who contracts for such projects
with a contractor(.) licensed pursuant to the Contractor's License Law,
❑ 1 em exempt under Sec. ,B s P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
,
Owner Dam
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
o hn"^ndwillmaintainaCertificateofConsenttoself-Insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Cotle, for the performance of the work for which this
y/-Z
R
Building 917.kDV
permit is Issued.
❑ I have Worker's
Seismic
and will maintain 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'.
Compensation Insurance
7
Qii
carrier and Policy number are:
Total /
Carrier Policy No.
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
A�nC ,l
7 e v ,. � �., z , p�1,
lJ V
COMPENSATION INSURANCE N, C.D
(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
All roofs shall be inspected prior to any roofing material being
any person In any manner so as to become subJoel to to rkare'compensation Laws of call.
forma.
installed. If a roof is installed without first obtaining an
Date Applicant - .
inspection, I agree to remove all new materials for inspection.
NOTI E TO AALItA-Nr If, after making thio a Ills Exemption, you should become
subject to the Workers' Compensation provisions 0 Ie Labor Code, you must forthwith comply
Applicant understands and will comply with all non point
with such provisions or this permit shall be of w evoked.
source regulations.
I certify that I have reed this application and State that the above Information Is correct, I agree
to comply with all city and county ordinances and stets laws relating to building construction, and
All roof coverings to be class "C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes,
"a) agree to save, Indemnity and keep harmless the City of Cupertino agalnet liabilities,
�� >` yZ9 ��
judgments, coals and expenses which may In any way accrue against said City In consequence
of the granting of this permit.
SIGNATURE OF APPLICANT' DATE
PRE -INSPECTION:
PLYWOOD:
IN -PROGRESS P 2 91996
INSP. DATE
INSP. DATE
INSP. DATE
TEAR OFF INSPECTION:
BATTENS:
FINAL: .it, t/r,url"'""
INSP. DATE
INSP. DATE
INSP. ' DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY