R 4937 (2) PERMITR_ 4 9 3 77
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
221 SrE N1 0 µ A L RESIDENTIAL COMMERCIAL OTHER
OWNER'S IHAZARDOUS FIRE AREA
NAME - `G ITA �= KLw�� YES ❑ If yes—I undersell that a Class A
roof assembly is required.
NO Inifil I.C.B.O.II
ADDRESS—S_ L� EXISTING ROOF COVERING
PHONE
gr13 -- 9511
NUMBER OF EXISTING COVERINGS
CONTRACTOR'$ ,,, /l7'1
V`
C� (:)OF7
` rmssr TO BE REMOVED TO BE RETAINED
NAME—
ADDRESS
ADDRESS `70 x q to3 CA+-to is-009 TYPE OF ROOF COVERING
CITY 8 ZIP
EXISTING
PHONE_ 1,1P9-r( 4-7 BUILT-UP ROOF gl
LICENSE
NUMBER Ot�1 9 �(41,1 ,❑`
`7 / ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby alarm that I em licensed under provisions of Chapter 0(commencing with Section WOOD SHAKES ❑
7000)of Division 3 0l the Business and Professions Code,anter 9 license Is In lull d force end
effect. Q
^/ - / WOOD SHINGLES;`; iti p ,- ❑ /
License CI s �I �� Llc.Number
-'� Cl til.Lgi1 ti OTHER(SPECIFY) ❑ - r
Data -BUILcler JUL 22 1996 /
OWNER-BUILDER DECLARATION PROPOSED 6
1 hereby alllrm that am exempt from the Contractor's License Law for the following reason.
(Sac
.7construct'alt Business and Professions ep it any Any city or county which requires a permit to ( I
applicnt,alter,Improve,tofile dampish,orstaementrthate,Is licenseor to Issuance,pursuant
reproves the BUILT-UP ROOF L/l k'Ur-G',r llpl
applicant for ,such permit a Ills a Cognate(Chapter 9(comm nci g i Ilceneetl pursuant to the provisions
of the Contractors Llcense Low)ortht h(commencing with Section 7000)of Division 3 le the
. Business and Professions Code)or that he Is exempt therefrom and the hale for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of healon hundred
by any applicant for o permit subjects the applicant to
e civil0penalty of not more than five by employees
yeedollsrw(h wag): WOOD SHAKES
❑I,k, owner of the property,or to employees with wepae(Stheir.7 sola compensation,will s. ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Coda:The Contractor's License Law 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 employees,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-butider will have the 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 contractor(s)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
El am exempt under Sec. ,B 8 P.C.for this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
1 hereby alllrm under penalty,of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compensation, ye' Buildinl,
as provided for by Section 3700 of the Labor Code,Mr the performance of the work for which this p /� W M
r p'A Is issues. ��� ` _ /J O I7o
have entl will maintain Workers Compeneatien Insurance,ea repaired by Section 3700 0l 7 l//\ $elsmic
Ih Lahr Code,for the performance of the work for which this permit Is issued.My Workers z] Total
Compensation Insurance carrler�entllPo'licy number are; �y�j �j �x/� ^,I u 6
•t Carrier lfzU^J6 PolicyNo.66 • •ill l• 4 "y*(,FERMI THORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.D ,rryyyV
(This section need not be completed If the permit is for one hundred dollars(8100)or lees.)
1 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 Cali- All roofs 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.
OT CE Tbecome
subject I.theeWorrkeres'Compefnsati n proviAPPLIANi I,after sionls of theliLaborr Code,Exempt
mustiaen1 whouflth comply Applicant understands and will comply with all non point
with such provisions or this permit shall 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 beS C'or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in. qn/ /)
sppurposes. /y „ _ �t
(We)agree to neve,Indemnify and keep harmless the City of Cupertino against liabilities,
/ —7—Z
(We)
judgments,costs and expenses which may In any way accrue against said Cry in consequence• SIGNATURE OF APPLICANT DATE
of the granting this permit.
l
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
JINSP. 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
nFFlre rnVV