99090057 6G 7 0 0 a5
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBS
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)7T7-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
�lDl� .VES C] II yeaI understand tiled. Claaa A
NAME v(� root assembly is required.
,^/G2 � �J /• / NO ❑ Initial LC.B.O.N
ADDRESS r4 `G �M/J�cO-.cl��cf t!/GL EXISTING ROOF COVERING
461
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S /J
/��� I�7 / - _ 7I TO BE REMOVED TO BE RETAINED.
NAME �/V l.lf�L(!1
ADDRESS //m�fJ//�) X33 ,(y' TYPE OF ROOF COVE
CITYBZIP / 'v/r/�/ �� -
2 - EXISTING p
PHONE- -?7 -7 _ 3 // - - BUILT-UP ROOF
LICENSE /
NUMBER (� 7 Z 2 ASPHALT SHINGL S-- /
LICENSEDunder FACTORS DECLARATION
hereby affirm that em Business
under Professions
loss of Chapter y(coma eIs in with f rce and WOOD SHAKES
7000)of Division 3 of the Busirrees entl Prolesslons Code,and my Ikeree fa In lull force entl U
effect y
z�4'� WOOD SHINGLES SEP - 1999
license Gess Llc.Number
OTHER (SPECI El
ContnCtpr r1 -
OWNER-BUILDERDECLARATION By
PROPOSED
I hereby affirm that I am exempt from Ne Contractor's License Lew for the following raasm.
(Sec.7031.5,Business and Proun slons Code: Any city or county which requires a permit to
crostn ,after,improve,demolish or repair any structure,prior toits lsauerre,alsofailulresthe BUILT-UP ROOF Elapplioant for such permit to INS a signed statement that he Is Roamed pursuant to Ne provisions
of Ne Contractoes License law(Chapter 9(commenclng with Section 7")of DMelon 3 of the
mi
Business aProfeselcrn th
Coce)or at he is exempt IhSalim and the basis for the Staged ASPHALT SHINGLES ❑
• exemption.Arty violetlm of Section 7031.5 by applicant for a perrNt Subjects Me applicant to
a dull penety of rxN mora then live h red len(55001 J:
❑I,ea owner of the property. amp wages as their sole compeneatlon,will do WOOD SHAKES ❑
Me work,erns the structure Is an or off for side(Sec.7044,Business am Proles.
slons Code:The Cmtrador se do ply to an owner of property who Wilds or WOOD SHINGLES
improves thereoq entl who d e ch rk h II oehmuBh his own employees,r Improve Nat ❑ A�
such Imignwithin one years not plat tl oHeretl sale.If,however,the en of pr vi Improvement
bsoltlld orr neya for purpoeuon, eowner-Wilderwill here Mus burden of proving that he did OTHER (SPECIFY)
- ❑
not build or improve for purpose of le.).
❑I,as oMler of Ne property,e exclusNely conirecllnp wlN liceneetl contmctore to construct
Ne project(Sec.7044,Busmasa and Professions Code:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property weto Wilds or Improves Manner,entl who contracts for eurh projects
with a contrarper(s)licensed pmsuarn to Ne Contractors t.lcense law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sac. ,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 the plovving docaratbn: I��rOl✓
1 have and will maintain a Certificate of Consent to self-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
permit is Lsaued. Sets I
I have and wig maintain Workers Compergi Insurarrce,as required by Section 3700 of C �'�
the Labor Code,for the pedormence of Me work tar which this Permit is issued.My Workers 7V
Compensallpn m car entl Pol' mbar ere: 4A. Total J�
carrier _-��� Policy N0. �� ¢4 cocl3lG PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CO
(This section need not be completed It the permit Is for me hunt dollars($100)or less.)
I cartity that in the performance of the work for which this perms Is issued,I shall not empty
any person in arty manner so as to become subject to the workers'Compensation we of Cal All roofs shall be inspected prior to any roofing material being
forma. installed. If a roof Is installed without first obtaining an
Data�� Applioant �� inspection,I agree to remove all new materials for inspection.
NO E APPD NT: II,after mekJng N erlllkate of Exemption,you slrpuio me
subject to t Woken'Compensation proviskxu of the Lebo;Code,you moat for p Applicant understands and will comply with all non point
with such provisions or Nle permit all be deemed revoked. - source regulations. -
I certify that 1 have road!Nle application and elate that the above Information Is correct.igr
to convey with all city and county ordnancee ami state laws relatingto WikBup_2,rctlon,anti All roof coverings to be Class rbetter.
hereby audrorium representatives of this city to enter upon the above-mentimed property ler III
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, -
judgments,costs end expensea which may In any way accrue against sold Clry In consequence SI URE OF APPLICANT DATE
of Ne granting 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
OFFICE31COPY q