99080153 4 Di
PERMIT
APPLICATION FOR CITY of CUPERTINO NUMBS
INSPECTION DIVISION pERMIr ExPIRAr1 N
REROOF PERMITr� (408)777-.3226 PERM R EXPIRES IF WORK IS NOT STARRED
WITHIN 1W DAYS OF PERMIT ISSUANCE OR
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING
ADDRESS /
Q y
Fe -r t vA / �r f V F RESIDENTIAL COMMERCIAL OTHER
OWNER'S < ^/ HAZARDOUS FlRE AREA
NAME DO"�I l L A U YES ❑ If yes-I understand Utat a Class A
ry roof assembly Is required.
NO, ❑ Inlbal I.C.B.O.tt
ADDRESS EXISTING ROOF COVERING
PHONE _ NUMBER OF EXISTING COVERINGS y
CONTRACTOR'S rr1 ? /1 ry
NAME
Ct3 Y� -�+'"'��• TO BE REMOVED J-• TO BE RETAINED —rCJ
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP ��� �lorT�, F-krD �Tk .
EXISTING
PHONE V 08 Zq Z 4j I FS^X BUILT-UP ROOF ❑
LICENSE �Ca06�—I - ASPHALT SHINGLES
NUMBER ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm tial I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
]000)of Christian 3 of the Business and Professions Coda,and my license is In full force and
effect.
WOOD SHINGLES G+/
'
Ulcerate Claw - Lic.Number 77
Date Contractor OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt horn Licence,Contractors LiceLew for the Iolloi reason. ✓
(Sec.7031.5,Business and Profeselana Cade: Amy city or county which requires a permit to
conetruG,all limprow,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF
applicant far such permit to IIIe a signed statement that he is Bcensed pursuant to the probidons
of the Contractor.License Law(Chapter B(commencing with Section]000)of Division 3 of the EByEl
Bueneas antl Professions,Coda or that he b exempt therefrom end the basis fon the alleged ASPHALT SHINGLESexamines.Any violation of Section]031.5 by any applicant for a Permit subjects the applicant to
a Wil penalty of rpt more than five hundred dollars(5500).):
❑1,es owner of the property,or my employees with wages as Nair sole compensation.will do WOOD SHAKESO ��nnthe work,and Its Structure a nit Intended or offered for Sale(SBC.]044,Business and Proles- JJsions Cod. The Contractor.Lbanse Law does not apply to an owner of Property who bolds or WOOD SHINGLES
mprores thereon,and who does suolt work himself or through ha own employees,provided thatsuch Improvomenis are not intended or offered far sale.11,howeaer,the bulking or Improvement
Is add!within ora year of completion.the owner-auiider will have the budon of proAng that he didOTHER(SPECIFY)ns,build cr Improve for purpose of safe.).
❑1,as owner of the property,pm esdusively,contacting with licensed contractors to con smucIt
the protect(Sec.7041,Business end Professions Code:The Contractor's License Lew does rot PROVIDE I.C.B.O.REPORT NO.
appy m an owner of property who Wilde or Improves thereon,and who contracts for such projeco,
vyth a conimctor(s)licensed pursuant to ma Contractors License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason
Owner Data APPLICATION.DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of ate follicle ng doctorallon:
1 have and writ maintain a Certificate of Consent to sell-Insure for Workers Compensation, Building/2,7.---
as;
pnt is is forWSection3]00 of the Labor Code,fortheperformance of iha�rkforwhich this w /'
_WI b issued' `/(y// /`/'/G Seismic
h$uCand will IN pelf Worker.Compensation Insurance,this as required Section 3]00 of
C
the Labor Code,for the performance rtce of the work for which Ihle parmll a issued.My Workers Total /.70
Compensation Insurance carrier enol Policy number ere:
Censer �rfi-r6�uk•'kd PolbyNo. 10-7 :5E"-? PERMIT UTHO ZATION DATE
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION I
OMPENSNSURC
N.C❑
(This section need not be completed it fine pornll
Is for one hundred tlollere($100)or lees.) CV
I certify that In the performance of the vork for which this permit Is Issued,I shall not employ
any Penson In any manner so n to became subject to the Workers'Compensation Laws of Cell- All roofs sh be Inspected prior to any roofing material being
fomia. installed./f a roof is installed without first obtaining an
Data Applicant finspectiol I agree to remove all new materials for Inspection.
NOTICE To APPUCANT: If,soar making this Certificate of Exemption,you should become Applicant understands and will comply with all non viol
.ublocl to the WoMem'Compensation provisions of the Labor Code,your must forthwith compfy pP P Y P
with such provisions or this permit shall be deemed revoked. source regulations.
I certify that l ha is read this application and state that the above information Is conect.I agree'
to compy,with all city and county ndmicances and state laws relating to building construction,and All roof coverings to be class"C"or,better.
hereby authorize represeratNes of this city to enter upon the abwa-mendonetl property for In-
ep(Wepurposes.
(We) — `
)agree to save.indemnify and keep harmless the Cly of Cupertino against— IIebIlltlea,
of the grinning
Cosa and expenses which may in eM way accrue against.ad Cly In.onsyepuerpe SIGNATURE OF APPLICANT DATE
of the grenlinp 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
NOT OSHA APPROVED ACCESS TO ROOF'SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY