R 5491 (2) MIT
APPLICATION FOR CITY of cuPERTINo
NUMBER R-. 5 4 91
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 -
�23 _'
' afi rrp RESIDENTIiCOMMERCIAL OTHER
OWNER'S _ Ir.�(,� ,I_ , ��}y�,r HAZARDOUS FIRE AREA
NAME �-��e l �K Y 1 C.4 I '�F.L.FCL n,.._ YES ❑ If yes s I understand that. Class A
roof assembly is required.
Q a�1 NO ❑ Initial I.C.B.O.#
ADDRESS!/ �• .1 � �.UrY�'Ii 17D �Z/F4r' EXISTING ROOF COVERING
PHONE �1'- lU. NUMBER OF EXISTING COVERINGSr
CONTRACTOR'S -
NAME - ['.�+�'nn% L.� (�, TO BE REMOVED-----[—TO BE RETAINED
cADDRESSITYa P a(n�7 Y(AP 1a�-. GY> •95-/)I Z1rPEOFROOFCOVERING
EXISTING
PHONE- � ��;�J '
BUILT-UP ROOF ❑
LICENSE ❑ L
NUMBER ASPHALT SHINGLES L�
LICENSED CONTRACTORS DECLARATION
hereby inionaffirnn'that em si licensed antler provisions of Chapter 8(commencing wllf Section WOOD SHAKES ❑ Y(/�!
1000)of Division 3 0l the Business and Professions Cotle,and my license Is In full force and -T
effect.
39SI a WOOD SHINGLES El Cl a s Lie.Number (}'^q.�-I/ (SPECIFY)
Dale -BUILDER V OTHER SPECIFY
OWNER BUILDER DECLARATIONrsLicense
J_
IS PROPOSED U
hereby affirm that am exempt from the Contractor's Llcenee Lew for the requires
a reason.
(Sec.10315,Business and Professions Code: Any city or county which requires a permit 10
coticanelter,Improve,to file demolish. Statement that
prior lofts issuance,also requlrea the BUILT-UP ROOF ❑
of the Contractor's
for such permit Ib lila a signeddr 9(comm nci he is licensedSection
pursuant to the provisionsoth
of the .s an Pre License Lew(Chapter h(commencing with Section 1000)of for the a of the 9
exemption.
xe ptio entl violation of Coco)or that he is exempt infero and the basis for the alleged ASPHALT SHINGLES
7 axemppen.Any ltyofolt more than Section h031.5 undred any s($50mlora permit subjects the applicant to
a civil penalty ai not more than Ilya y employees
dollars(h wag): WOOD SHAKES
❑I,k, owner of the property,or to ded with wages as their Bole compensation,will do ❑
the work,and the structure is not Intended or 44 at
for sale(Sec.1044,Business end Proles.
impr Code:The Contractor's License La not apply to en owner of property who provided
t or WOOD SHINGLES ❑
improves ov m n,entl woo tlaea ouch wo l9e hale awn employees,provitletl ant
such improvements are
not Intentlatl aro a far eels. he building or Improvement
Is Id within one :arofcom 1: on,ihe butte 1 l ve the roving that he did OTHER(SPECIFY) ❑
Y P b- g
not bulltl or Improve for purpose of sale.. I -1�
❑I,as owner of the property,am ex lively contracting w Iicen con( aconstruct
the project(Sec.7044,Business and fjr-least
or qg The Canirectd's Lic w does not PROVIDE LC.B.O.REPORT NO.
apply to an owner of property who builds or lr a t$tlraEh,49d who conI It I uch projects
with a contractor(s)licensed pursuant to the C mtracltor'a. 0)".s PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. �JYy�B P.C r tale reeeon
Owner Date
WORKERS COMPENS9LION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
1 hereby affirm antler penalty of perjury one of the follbwlag-ILeclaration: wx
//7,�/
F ❑ have and will maintaino of the
ate bof Consent to Performance
Worker's Compensation,this � �V r`-" Building!/Y /ea provitletllardy Sedlonain a ofthe Lab or Code,for lhepednsure f rWorework r'sCfm enation, / ^Q
Patilesuetl. t S
'R'f have end will maintain Worker's Compensation Insurance,as required by Section 3]00 of �• Seismic
I L bar Code,for the performance of the work for which this permit Is Issued.My Worker's ) /q.J, rO
'Compensation Insurance carrier and Policy number are: Total I A
Carrier r PolicyNo. I ��� '•'-�� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTI FROM WORKERS'
COMPENSATION ANCE N.C.[]
(This section need not be completed II the permit Is for one hundred dollars($100)or leas.) V " " •�17 �-/1—
I certify that In the performance of the work for which this permit is Issued,1 shall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell- All roofs'shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will
subject to the Workers'Compensation provisions of the Labor Coda,you must forthwith comply PP comply P y with all non point
with such provisions or this permit shalli.ba deemed revoked. Source regulations.
I certify that I have road this application and state that the above Information Is correct.I agree
to comply with all city and county ordinances and state laws testing to building construction,and All roof coverings to be class°C"or tter.
hereby authorize representatives of this city to enter upon the above-montionetl property for In.
spection purposes. � /' _
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, — J -1
judgments,costa and expenses which may In any way accrue against Bald City In consequence NATURE OF AP LICANT DATE
of the granting of this permit.
. 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