R-5994 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 59 9 4
INSPECTION DIVISION - PERMITEXPIRATI N
REROOF PERMIT (408)777-3228 PERMIT EXPI RES IF WORK IS NOT STARTED
WITHIN 18D DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
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RESIDENTIAL COMMERCIAL OTHER
OWNER'S , - HAZARDOUS ll AREA
Q YES ❑ It yes—I urldomtand tfat a Clans A
NAME Aa SAxo�12A Lw gAD,� - - root assembly is required..
1, No ❑ Imbel I.C.B.o.r
ADDRESS �N�2 �aAlzL WAy
EXISTING ROOF COVPRING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
�►TAl'= l�tNL�Q' )t�� �• �la� TO BE REMOVEDTO BE RETAINED
NAME
ADDRESS a /� ^r TYPE OF ROOF COVERING
CITYBZIP 2�' 1Z Uo�•�t--1� P6, S'J . q�17J6
A , � EXISTING
PHONE 'T S `&A + BUILT-UP ROOFUCENSE 15 ❑
'
NUMBER 59�'�l. ASPHALT SHINGLES ❑
UCENSED CONTRACTORS DECLARATION ,x�
I hereby afftrm that I am licensed under proNelons of Chapter B(commenting with Sa WOOD SHAKES P IX D' '
]000)of Division 3 of the Burliness and Proleeslons Code,entl my license Is In lull b d
ems' WOOD SHINGLES A�r�
License Case� •"� Uc.Number `�'v'J p JUL 01tl r`D
Date Contractor /`TA� LCU'!'Ir�o .p- OTHER(SPECIFY)
OWNER-BUILDER DECLARATION CI.fY. Ur wur Gill lil
I hereby affirm that I am exempt from the Contractors License Law for the bllowing reason.
(Sac.7031.5,Business,and Professions Code: Any city or county which requires a permit to
canatil after,Improve,complbh,or repair any stnucture,prior to la Issuance,also requlret the B IL -UP ROOF ❑
applicant lot such permit to file a signed statement that he Is ticeneetl Wsuent to the provblont
of the ss and tort Liceree Lew(Chapter h Is ex(commencing t with therefrom
and 7000)si Division 3 of the *C�
ex a ptlo entl Pro lotion f Cade)or that he la exempt therefrom Intl Ise babb a lineapp icantalleged LT SHINGLE ❑
exemption.Any violation ol5ectlon]031.6 by any eppllcent bin a permll eubjeda the applicant to
a ddI penalty of rot more than five hundred dollars($S0 ft.):
❑I,as owner of the property,or my employees with wages as their me compensation,will do SHAKES ❑
the work,and the structure Is not Mended or offered for safe(Sac.7044,Business and Profes-
aloneCode:The Contracture License Law does not apply to an owner of property who bunds or WOOD SHINGLES
Improves(hereon,entl who does such work Nmeelf cr ihmugh Na own amp"",prod
ved that El such Improvements are rot intern ed or offered for tale.if,however,the Wlking or Improvement
Is cold within one year of completion,as owner-bulcer will he"the burden of proving that he old OTHER(SPECIFY) I
not bulk or Improve for purpose of sale.). .
❑I,as owner of Me property,am exclusively contecti�+g with licensed contractors to conetrucl
the project(Sac.]044,Business and Professions Cord 9 Contractors Llconse Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who Wilda or Improves thereon,and who contracts for such projects
with a contractolfiseneed punauem to the contractor,License Law. PROVIDE MFG R.INSTALLATION SPECS. -
❑I am exempt under Sac. ,B&P.C.for this reason
Owmar Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury ore of the fcllowing declaration:
❑I have and will menain a Certificate of Consent to seH-insure for Workers Compensation, BIId
as provided for by Section 3700 of the Labor Coda,for me performance of the work for which his Un g
Permit b Issued �/'y �]Q
,0have and will maintain Workers Corrpanealbn Insurance,as required by Section 3700 of lU( —1 O &50Seismicth/Rbor Code,for the periorman xi of the work for which this parmt a Issued.My Workers
Compensation Insurance carrier entl Policy number are: p a Total
Carder�j r� FU JD Policy No. yf 10 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' it
COMPENSATION INSURANCE N.C.❑
(This seclbn need not be completed H aro permN le bin one hundred dollars($1 0)or lees.) i vy
I cal Owl In the performance of Lha work bin Ice OJs permit Is Isauetl, °heti rot mp by
any person In any manner al as to bacorre suN o Lha e' ompenxtlon Lewy oaf CaIF All roofs shall be inspected prior to any roofing material being
/omit. n installed. If a roof is installed without first obtaining an.
Date �a ' Appl cart inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after makin b'Certfidsheo xempikn,you should become A hcant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Cade,you must forthwith comply PP P y P
with such provisions or this permk shelf be doomed revoked. - source regulations. '
I certify that I he"read This Application and state that the above Inbmnetbn tocomact.I agree
to comply with all city anti county ordinances ud stale laws hearng to building construction.and Allro COV ngs to class'C"or better.
herapy authorize repe°enatives of the city to enter upon the above-mentioned.property for In.
spection purposes. 7 l�-9vfj
(We)agree b°eve,Indemnity and keep harmlessway the City of st sald Ci against labllltles, . 7K
of%ttgran costs f entl permittee which may In any way a«me against sem City In coneequerrce NA URE OF P L T DATE
d the granting of ab permit.
- PRE-INSPECTION: PLYWOOD: 7' IN-PROGRESS: -
INSP. DATE INSP. 4� DATE v INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE ✓
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY