991100540
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PERMIT
APPLICATION FOR CITY OFCUPERTINO NUMBER
INSPECTION DIVISION - PERMfT EXPIRATION
REROOF PERMIT (408)7T] -,3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
"
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
YES ❑ H yes - I understand fhaf a Class A
NAME
roof assert" is required.
NO ❑ Initial I.C.B.O.Y
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ADDRESS" oG�(O "" `�� 7
EXISTING ROOF COVERING
/
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PHONE �'f/ 0 01'5 Z —S9 93
NUMBER OF EXISTING COVERINGS
TO BE REMOVED TO BE RETAINED
OR
CO // /�
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NAM `—
ADDRE S �I wD I n �^'
CITYBZ c�a- AW
IYEE OF ROOF COVERING
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EXISTING
�, % 19 -U70 /
PHON&9 T
BUILT -UP ROOF ❑
LICENSE
NUMBER S
ASPHALT SHING ES ❑
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D SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I licensed Chapter a Section
em under provisions of (commencing with
70)0) of civil 3 of the Business and Professions Code, and my license Is In full force and
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effect. ]x r "yam
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HIN LE
NOV -X1999 D
License Class Lk. Number •
I
n�R
P
Date CaNmctor -
OWNERBUILDERDECLARATI
BV
1 hereby affirm that I em exempt from the Contmctor's License Law for the following reason.
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(Sec. 7031.5, Business and Professions Care: Any city or county which requires a permit to
construct, alter, Improve, demcalsh, or repair any structure, prior to Its Issuance, also requires the
BUILT-UP R OF ❑
applicant for such permit to file a signed stetemant that he Is licensed Pursuant to the proWSbns
of the Contractor's License Lew (Chapter B (commencing with Sec m llon 7(00) of Direct 3 of the
Business and Professions Code) or at he Is exempt therefrom and me basis for the alleged
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ASPHALT SHINGLES Cl
7 0
exemption. Any vldatbn of Section 7031.5 by any applicant for a permit subjects the applicant to
a evil penalty, of rat more than five hundred dollars (5500).):
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I, as minor of the property, or my employees with wages as their sole cominensetlan , will do
W D HAKE
WOOD ❑
the work, and the structure is not Intended or offered for eab (Sec. 7044, Business and Proles -
slons Code: The Contractor's License Law ease not appy, to an owner of property who builds or
WOOD SHINGLES ❑
Unprovas thereon, and who does such work himself or through his own employees, provided met
such inrprovomems are not Intended or offered for sale. If, howoyar, me bulkiing or Improvement
- !�V /1 1- ✓
Is sold within one year of completion, the ownenbulloer will have the burden of provlag met he did
OTHER (SPECIFY) ❑ //1. {:.. V/�
not build or Improve for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with Ilcensed contractors to construct
the project (Sec. 7044, Business and Professlorm Code: The Contractor's License Law does not
'
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who Wide or Improves hereon, and who contracts for such projects
with a contractor(s) licensed pursuam to the Contractors Uaarme Law.
PROVIDE MFG R. INSTALLATION SPECS.
❑ 1 am exempt under Sec. ,B 6 P. C. for this reason
owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
1 /l�j_
I hereby affirm under penalty of perjury one of the following declaration:
11 here anal will maintain a Certificate of Consent to self - Insure for Worker's Compensation,
as provided for by Sooners 3700 d IN Labor Code, for the Performance of the work for which this
Building II"t T O�
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permit is Issued.
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, 3 /410
Seismic (— q
!\�/I and will pelf Workers Insurance. as required by Seddon
`h_a-ve
Me f the work
th9`� Cade, for the performance of the work for which this permit a Issued. My Workers
orke s
-
Total
Compensation Irreu tike cam -er�pM PoI''�jcamber ere:
7 27 -,�9-093
Carrier � .Policy No.
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.Cj]
(This section need Prot be completed If the Permit is for one huralred dealers ($100) or fees.)
1 calGfy that in the performance of the work for which the permit Is Issued, I shell not employ
_
All roofs shall be Inspected prior to any rodfirig material being
any parent In any manner so as to become subject to the Workers' Compensation Laws of Cell-
farm
installed. If a roof is installed without first obtaining an
Date C1 Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE APPLICANT: If, after maidng this Cergt cote of Exemption, you should become
subject to the Workers' Comperuatlon provisions of me Labor Code, you must fodhwith comply
Applicant understands and will comply with all non
pp P Y point
with such provlsbrs or this attract shall be deemed revoked.
source regulations. '
I certify that I have read the application anal state that the above information Is correct I agree
to compy, with all dry and county ordinances and state ewe relatlrg to balding construction, anxd
All roof coverings to be class or better.
hereby'authorbe representatives of this dry to enter upon the above- mentioned property for In-
specaon purposes.
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(We) agree to save, Indemnity and keep harmless file City of Cupertino against liabilities,
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ju jarents, costs and expanses which may in any way source against sole City In cons,q a
SIGNATURE APPLICANT DATE
of tFa granting of this permit.
PRE- INSPECTION:
PLYWOOD:.
IN- PROGRESS:
If DATE
INSP.—DATE—
INSP. DATE
TEAR OFF INSPECTION:
BATTENS:
FINAL:
INSP. DATE
INSP. DATE -
INSR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY