99100110 /oo/ O
PERMIT
APPLICATION FOR CITY of CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMITEXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
. 100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES E] If yes— understand iJ1at a Class A
NAME root assembly is regidred.
NO ❑ Initial LC.B.O.B
ADDRESS S� L.r�tz.�(' 1��t9� L7� • EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERIINQRI
CONTRACTO
NAME H(+ TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP -
G\ nn EXISTING
PHONE��e �SQ BUILT-UP ROOF � �
LICENSE /
NUMBER ASPHALT SHINGLES
DCEN D CONTRACTORS S DE hapten (commencing /�
herf DI Ieum Inst I em shah s under preWsbre of Chapter 9 sInwith Section 'WOOD SHAKES - ❑ ��77
1000)of DivLsion 3 0l the Bueirlaes arrd Professions Code,antl rtry license Is In lull bete and Loffeca
icense
WOOD SHINGLES ^ ❑ 9
Lkenee Clear `✓ Lic.Number D G/.�\
B _ ` OTHER(SPECI []
'
Date Contractor � -
OWNER-BUILDER DECLARATI PROPOSED OCT 2 0 1999
I hereby affirm that I am exempt from the Contractors Umme Law for the following reason.
(Sec.1031.5,Business and Protractors Code: Any city or county which equities a permit to
construct,atter,Improve,demollrh,or repelr any structure,prior to its Issuance,also requlres the BUILT-UP ROOF ❑
appkcant for not permit to me a signed statement that he Is licensetl pursuant to the povblarls
of the Contractors License Law(Chapter 9(cornmeal with Secten 1000)of Damian 3 of the
. Busies^and Profession.Code)or that he Is exempt therefrom and the beers for are alleged ASPHALT SHING y
"sorption.Any'-clledm of Seeded 1031.5 by any applicant for a permit subjects the applicant to
a del penalty of not more then f"hundred diallers($501
01,as owner of the property,or my employees with wages as their sde mndmintbn,will do WOOD SHAKES ❑
the work,and the structure is real Intended or offered for sale(Sac.1044,Bualnesa and Prefes-
sure Code:Tho Contmdoes License Lew does not apply to an owner of property who builds or WOOD SHINGLES ❑
improves thereon,aro who done such work,himself or through his own employees,Finaidad that
such Impro'.emenla are not Intended or offered for sale.If,howxver,the building m Improvement
Is sold within one year of completion,me"wnrr-builder will have the burtlen of proving that he did OTHER(SPECIFY) ❑
not bulb or Improve for purpose of sale.). -
❑I,as owner of to property,em exclusively contracting wtlh Ibrn.ed contractors to construct
the project(Sac.1040.Busbers and Professlore Cone:The Contractors License Law dose net PROVIDE I.C..B.O. REPORT NO.
apply to an owner of property who builds or Improves thereon,and who mntrects for such pedalo
with a mnterctor(s)licensed pursuant to the Contractors License Law, PROVIDE MFGR.INSTALLATION SPECS.
I]1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE -
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of Perjury one of Ihr following declaration:
❑1 neve end will maintain a Ce ufimte of Consent to sen-Insure for Worker's Compensation, BUlldln
m provld ci for by Section 3100 of the Lobar Cotle,for the performance of the work kx which IN. . ,w Q g
perm I.an od. (Q 7
have and will maintain Workerm
's Copmeatbn Insurance,as reqcti
required by Seon 3100 of r Seismic
N La r Code,for the concurrence of the work for which this permit is Issued,My Workers
Companeatbn Insu rice caroler aro Pdlryyumber are Total 1�0
Coater u�`•/'-W,N/ Policy No PERMIT AUTHORIZATION DATE
CERTIFICATEOF EXEMPTION FROM WO KERS'
COMPENSATION INSURANCE N.00
(This section need not be completed It the permit is fm one hundred dollars($1 DO)w less.)
m ( O, 2 0
I eerily that In the perlcrmarge of the weak for wnbh this permit Is Issued.1 shall not eby
any persin any mariner for as to become subject to the Workers'Cone enmtlen Leve d m teen- All roofs Shall be inspected prior to any roofing material being
formla. installed. If a roof is installed without first obtaining an
Date ApPliram inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: 11,after mating this Cervical of Everiffietted,youIBshouldhbemPy
subject to the WorkarApplicant understands and will comply with all non Workers' parnsbns d the Labcr Code, point
with such provisions or this permit shall be deametl revoked: source regulations.
I mrdy that I hme read this appllcedon and elate that the above Information Ie matt.I agree
to comply with all cry ame!county ordinances and state laws relating to toildflng construction,and All roof coverings to be class Orbe
hereby euthort representativws of this city to enter upon ttre ebovamentbned property for In-
spmclm pugeases. O`
Judgments,costs a(We)a9r e,to save,Indemnity and keep harmless the City of Cupertino against Ilobllltlee,
aro expenses which may In any way accrue against said Cly In consequence
of ire gmndng of ws permit. SI—GNATLIFIE OF LI ANT DATE-
PRE-INSPECTION: PLYWOOD: I -PROGRESS:
li 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 '