R-59040
•
OFFICE COPY
PERMIT R- 5904,
APPLICATION FOR CITY OF CUPERTINO
INSPECTION DIVISION PERM IT EXPIRATION
- REROOF PERMIT (408) 777-3228PERMIT EXPIRES IF WORK IS NOT STARTED
- WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
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RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
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YES 1-1If yes - I understand that a Class A
NAME ✓'
roof assamby Is required.
NO >< Initial I.C.B.O. Y
ADDRESS - JS
EXISTING ROOF COVERING
.NUMBER OF EXISTING COVERINGS •j- '
'
j-
_
PHONE N/A
CONTRACTORS
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S �N V (26 . INC
NAME "e-IUA-15 4*Ur— e— XQO
NAME t
TO BE REMOVED TO BE RETAINED
OF ROOF COVERING
ADDRESSTYPE
I— :)s -err
crrYazlP 1-29 L a,__nL_.v .4Ue- cS
tlO
PHONE o00
BUILT-UP ROOF El
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LICENSENUMBER SS �� ���/ZPS 3 ,2/ 99
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ASPHALT SHINGLES �❑_ /
DECLARATION
underr sof
provisionsCONTRACTORS
I hereby affirm that I em licUCEensed Chapter 9 ((commencing with Section
WOOD SHAKES IM
70001 of Division 3 0l the Business and Profeselond Catle, entl my license Is In lull bice eM
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C�Q SS(?��
WOOD SHINGLES ❑
eyaffect'
License Class �— Up. Number
Date - Z3� ��g9 contractor Re.U.G/SSAACP .(bCY'/.(/G
OTHER (SPECIFY) ❑
OWNER43UIMER DECLARATION
I hereby affirm Met at I am exempt from the Contractor's License Law for the fol owing reason.
PROPOSED .
P �?yG
(sec. 7001 5, Cade: Any dry or county which requires a ro
and Profedemolish,
prove, d or rep atrenyettat e, poor to pe Issuance, sir s t
after, motors, grouse the
BUILT-UP ROOF
forsch
Ionsuch permitto firs asigned Islicensed!Wr00) fto Me pro
appliconstcant unt to ft
of aChapt
r 9(comnt:hethe
Me Co of the
of the Contractor's Otiose Lew (Chapter S (commenting with Section the b a for Mel 3 al the
La
Business and Prolesakns Code) he B exempt Merofra and the be for app slant
ASPHALT SIHINGLf J
7that
violation Section 7undredy°rryappllca). braparmk sub7acis the epPlkantro
t, up
a chit penalty of
e tivil of trot more pert Ilve doaarw (h
V/)y
. as ow y eninpl wage �
lt 7sale compensetlon,willdo
property,orItended loyeeered for
❑I,k, for
the the Is Intended 7044. rephase
WOOD SHAKES
04,455 4
and structure eels (Sec. o-
work, entl not ale(Sc.
or s not
and builds
Contractor's Llamas Lew titlesnotapply toenowner of property whobetide
slonsCoo°:The,an through his
Improves thereon, titled pal
WOOD SHINGLES - '
❑ S
who
entl who deco work or own amp"", t
1401ji�
offered
Intended or offered for idle. :limer moran,e
however, the bulking or improvement
Isco Impmvememe are notcompletion,
ill
will have the burtlenofproving Mat hetlk
OTHER (SPECIFY) j�Y/CQ. (L/GCirs.¢1G�i
notI III prow,fnofcomseofstheowner-balker
not bulltl err Improve for purpose of sale.).
01, as owner of the property, am exclusively contravingwllh liconeeo contractors to construct
the project (Sec. 7044, Business and Professions Cade: The Contractor', License Law does not
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PROI I.C.B.O. EPORT N % J
appy to an owner of property who bulks or Pnprovos thereon, and who contracts for such protects
with a cont&ctm(s) licensed pursuant to the Contractors ucenee law, -
-11
PROVIDE MFGR. INSTALLATION SPECS.
em exempt under Sec. ,B & P. C. kr MIs reason
Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
rt�
7
I hereby efflnn unbar penalty of perjury oro of the following declaration:
❑ 1 he" and will maintain a Certificate of Consent to eellaneure kr Worker's Compensation,
Building L
ee provloeo for by Section 3700 of the Labor Code, for the perkxmence of Me work kr which this
,MRJa leeuetl.
19ihave eM will met erf Workers Compensationa Insurance, as required by 3700 0l
q qo
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1936,s -
Seismic 2,od
wonfor
Code, work d, My
�t whloh Mie permit Is leauetl. My Worxere
the performance o/ Policy
Ineurarae
P
Total O
al��yor
mpenealkn ur r a
tenor end,Po1 hic'y number are: )s/)(
STiQ'TL AW
�Y253
PERMIT AUTHORIZATION
DATE
/1C%) PollryNo.
Corder
CERTIFICATE OF EXEMPTION FROM WORKERS'
^/ 7
COMPENSATION INSURANCE N.CQ
(Thus section need not be completed 1 the permit Is for one hundred dollars ($100) or lees.)
I wrttly Ihal In the pdrlormance of the work for which Mie parmp Is Issued, I shell not empIoy
any person In any manner w as to become eublea to Me Workers' Compensation Laws of Cah-
t
All roofs shall be Inspected prior to any roofing material b Ing
fornla.
Installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, shot mekrp this Certificate of Exemption, you should become
subject to Me Workers' Compensation provfelons of Me Labor Code, you must forthMM comply
Applicant understands and will comply with all non point
SIM lunch provision& or this permit MIB be deemed rooked.
Source regulations.
I tartly, Must l have read Miss application entl state Mat Me above lnlormabon la correct .l agree
to comply with all dry entl county oNlnences orb state laws relating to building coneVucpon,entl
comply with ell city entl county aro state laws to ,entl
Atoc1l ere r.
Al
lto
hereby authorise representafhves of this city to enter upon the above-mentioned property for In-
spection purposes.
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(We) agree to save, Indemnity and keep harmless the City of Cupertino against Hadbittles.
Judgments, coats and exparmin which may In any way accrue against said OR, In conaequanco
of Me granting of MU permit.
DATE
PRE -INSPECTION:
PLYWOOD, X
IN -PROGRESS: AC
6
INSP. ---:-DATE
INSP. —` DATE
INSP. DATE
TEAR OFF INSPECTION:
BATTENS: X
FINAL:"
Q�X
��
INSP. DA�w a
INSP. DATE
INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY