99120074 35- 7 a0 (0160
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBE
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WTmIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS
�AA�fGC.- Ava RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS AREA
•, VES C] If yes—I understand that a Class A
NAME t/! LV I roof assembly Is required.
?� NO E] Initial I.C.B.O.Y
ADDRESS
723" Te jica Ave EXISTING ROOF COVERING PHONE Ver
L p�,c er o " 7ZS— 1 0 V / NUMBER OF EXISTING COVERINGS
CONTRACTOR'S - '/
�T /bJFiJCJ TO BE REMOJED I TO ERETAINED
NAME
TYPE F RING
ADDRESS yzo3s IDS r�P, r, r���r�
q EXISTING L,
PHONE SIO y30 - !0 7 7 BUILT-UP ROOF / T"
LICENSE 7S5'-�5S ASPHALT SHINGLES
NUMBER ❑
LICENSED CONTRACTORS DECI-MRAMON
I hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES
7000)of Diveon 3 of the Business and Professions Cook,arta my license Is to full force and
effect.
WOOD SHINGLES ❑
Los."Cl. � —�� LiC.Number -7 53-75/G
Data /Z'�� Central .uwucLf{ at�sl=yam OTHER(SPECIFV)D q❑ n
Opt from BUILDER Dtora UcTI PROPOSED pE U
hereby ollBu that am exempt coon the Contractor's License Law I«the meas ng Permit
t.
(Sec.7031.5,r,Improve,
and Professions it any Any cry or county which requires a permit to
applicant,altar,Improve,compto file signed statement Iran
prlorto Its issuance,pursuntelsorequirea the BUILT-UP ROO 14999
of Me Co for such permit to Illy aChapt statement that he Is h Sento pursuant to the provisionsofthe
of the Contractor's License Lew(Chapter h is ex(commanding V with Section the b of 10,me 3 le the RI,
Business and Professions Code)or that he is any
Marefram and the basis for ha ica ntto ASPHALT SHINGLE
• a civil en.Any violator of Section 7031.5 fry elry applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dollars($500).):
❑I,as owner of the property,or my employees with wages as their sole compeeation,will do WOOD SHAKES
the work,and Me structure is not intended or offered for sale(Sec.7004,Business and Prefers.
sions Code:The Contractor's Dcense Law does not apply to an owner of property who builds or WOOD SHINGLES 1:1Improves thereon,and who dms
does such work himself or through his own wr pkryees,provided that
such Improvaments ere not Intended«offered Mr sale.It,however,Me bullding or Improvement
is auks wlMln one year of completion,the owner-builder wilt have the burden of proving Met he did OTHER(SPECIFY) ® Ly Fe
net build or inarove for purpose of sate.). '
p 1,as owner 0 Me property,am exclusively contracting W IM licensad contractors to construct
he project(Sao.7044,Business and Professions Code:The ConiractoYe lxenae Law class not PROVIDE I.C.B.O.REPORT NO. ;?09
apply to an owner of property who builds or Improves Marson,and who contracts for such projects
.with a contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
I am exempt under Sac. ,B 8 P.C.for this reason
owmar Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the forowing declaration:
1 have and will maintain a Certificate of Consent to se11-Insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 7
Perron Is Issued. 4 // D 0O Seismic
I have are will maithe performance
Wader's Compensation work
Insurance,as reitis i by Sedan Workers
0l (((
the Labor Code,for the performance of he work for winch this perms is issued.My WorkeYs
Compensation Insurarke carrier and Poi/lc�y number are: Total x
Carrfer 5'/YfTE �NF/ Policy No. 0Y6dL") ZK PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATIONINSURANCE NCO
(This section di not be completed If the permit Is for one hundred d ($100)or lase.) Z O��
I c«tlty that In the performance of the work for which this permit is iasuetl,I shall not epi
any pereon in any manner par as to become subject to the Workers'Compensation Laws of Cali- All roofs shall be inspected prior to any roofing material being
fpm . installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for Inspection.
NOTICEMe Workers'
e after do prong this f the Certificate of o Exemption,mustufo�UhE�Ply Applicant understands and will comply with all non point
subject to T APPU'Com ,rection kfing t is al hif Labor Code,
with such provisions or Mb pepri shall he deemed revoked. source regulations.
I certify that l have read this application and state that he above slannabon is wrrecr I agree
to comply with all city and county ordcsnces and state have roasting to bulolrg constraction,and All roofC n gs to be class"C"or better.
hereby authorize representatives of his dry to enter upon the above-mentioned property for In. ,{�
spectnn purposes. r "_7/y f
(We)agree to save,indemnity entl keep harmless the City of Cupertino against Liabilities,
Judgments,posts and expanses which may,In any way acoue against cold Dry In c«sequernce SIGNATURE OF APPLICANT DATE
of the grarwi 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
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY