R-53011
- PERMIT R_
5 3 Z
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1W DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
9UILDING(pA�DDRESS
oa'\
�j '✓�1
RESIDENTIAL COMMERCIAL' OTHER
OWNER'S
HAZARDOUS FIRE AREA
1
that a Gass A ,
VES ❑ Ifthes-roof
NAME _ ia� : ` 0 1' 1Q+5
IataM
roof essarMly Is required.
assembly
NO A Ir1Aal I.C.B.O. X _
�V�tf
1
EXISTING ROOF COVERING ,
NUMBER OF EXISTING COVERINGS 1
ADDRESS
— 1
PHONE J 1\15 per—
CONTRACTOR'S
NAME Q-0b7ii Q u (� �'rC
TO BE REMOVED I TO BE RETAINED
TYPE OF ROOF COVERING '
CITY 8 ZIP
EXISTING
Q
C\i
PHONE�
BUILT-UP ROOF ❑
LICENSE q
NUMBER v U plL
ASPHALT SHINGLES 1<
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am Ikausk! under provisions of Chapter 0 (commencing who Section
7000) of Division of fire Business and Probsslons Coda, and my license Is In full force and
anent.
Dcance Glares Lk. Number
INGIS
IFPECIFY)Data
Contractor
ContraDER
2 1999OWNE
LA
DECLARATION
I hereby. affirm that I am exempt from the Contractors License Law for the folkwtlng reason.
(Sec. 7031.5, Bualnees antl Professore Code: Any city or county which requires a panni toconstrue,
alter, Improve, demolish, or repair any structure, poor to Its Issuance, also requires the
ROOFapplicant
for such Permit to fife a signed statement that he Is licensed pursuant to the provisions
of Me Contractor's Ucerse Law (Chapter a (corrvn mcing with Section 7000) of Division 3 of theBusiness
and Pridefu lona Code) or Chet he Is exempt therefrom antl the baste for the alleged
Elexemption.
Any violation of Section 7031.5 by airy applicant lore permit subjects the applicant to
a tivil penalty of not more than five hundred donate ($500).):
WOOD SHAKES
01, as owner of the property, or my employees Mth wages as their sole compensation, will do
❑
the work, and the atruciure Is not intendetl or offered for cele (Sec. 70". Business end Profes-
IonsCoda: TheContmctoraLicenseLawdoesnotapplytoanowrewofpropertywhobusbeor
Improve, thereon, and who doesch suwork tdmai or through his own emploees, yprovded Mat
WOOD SHINGLES ❑
-
such Improvements are not Intended or offered for sale. It, haweveq the bulking or Improvemant
Is sdtl within one year of Completion; the owner4iullder will have the burden of proving that he did
OTHER (SPECIFY) •- .J
not oulld or Improve for purpose of sale.).
❑ 1, as owner of the property, am exclusively convecting with licensed contractors to construct
the the prolect(See. 7044, Business and Professions Code: The Contractors License Law does not
PROVIDE I.C.B.O. REPORT NO. ASS
apply to an owner of property who bulide or Improves thereon, and who contracts for such projects
with a contractor(s) licensed pursuant to Me Contractor's License Law.
PROVIDE MFGR. INSTALLATION, SPECS.
01 em exempt under Sec. ,B a P. C. for MIs reason
Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
%
I hereby affirm under penalty of perjury one of fine following declaration:
❑ 1 have and will maintain a Certinca a of Consent to setldnsura for WorkerC
Worker's mpenestbn.
Building Y7
as provided for bySectlon 3700 of the Labor Code, for the pedarmance of Me work for which this
permit
-
boo
/
10
Seismic
r-lIelssued.
❑ have and forill maithe per rm,ancWorker's fo vo sib r whichn id.e. as required by d. My 3700 Workers of
dw Labor Code, for Me pedorrnerwe of tM work for which Mle pmmlt Is lsauetl. My Workers
Compensation Insurance canner andicy number are: ``\`(� I_ �
Cent PdkYNaWV�O�UINW
CERTFICAtE OF EXEAIPnON FROM WORKERS'.
Total
PERMIT AUTHORIZATION
DATE
' �p
'
Z —(::?.p
COMPENSATION INSURANCE N.CAD
(This asi need not be completed n Iva permit Is for one hundred dollars ($100) or less.)
I cariHy that In the pedotmen na of Me work for which this permit Is issued, I shall not emoy
any person In any manner co as to become soil to the Workers' Compenaatbn Lowe of
All roofs shall be inspected prior to any roofing material being
forma.
installed. If a roof is installed without first obtaining an
Data Applicant
Inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, after making this Certificate of Examptbn, you should! become
Applicant understands end will comply with all non"point
PP Ply
subject to the Workers' Compensation provisions of the Labor Coda, you must forthwith compty,
with such pmvlelons or this permit s IV,ba Ceamad revoked.
Source regulations.
I certify Mat I have read this application and state that the above Information Is correct.I agree
to comply with all city and count' ordinances and state laws relating to bulding co stmcdco, and
All roof Coverings to be Class'�r better.
hereby authorize representatives of this city to enter upon the above-mentioned property for Iry
spection purposes.
(We) agree to sew, indemnity and keep harmlece the City of Cupertino apalnst liabilities,
jukigmenta, cost, and expereae which may In any way accrue against said Ciry itansequance-
SIGNATURE A CA DATE
olMegranting ofhow Permit
PRE -INSPECTION:
PLYWOOD: -
IN -PR -
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