R-64710
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OFFICE COPY
PERMrr R- 6471.
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES F WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM UST CALLED INSPECTION.
BUILDING ADDRESS -
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RESIDEN COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
Gia7>,Q �ocvt�m�Mu,►ys
YES ❑ Hyes— I understand that a Clal
NAME 1A)Q
of a%SerMly 1e required.
NO Initial LC. B.O. N
EXISTING ROOF COVERING
q ��/�y/�•./- I r WOW 5rf
ADDRESS
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NUMBER OF EXISTING COVERINGS /
PHONE I I��/
TO BE REMOVED „ TO BE RETAINED
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ADDRESS 5� '/^ /f f
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-TYPE OF ROOF COVERING
CITY&ZIP ✓C/�/I!
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PHONE 13
BUILT-UP ROOF
LICENSE -
'
NUMBER / 0
ASPHALT SHINGLES ❑
DCENSED CONTRACTORS DECIIAATION
I hereby affirm that I em licensed under provlaons of Chapter B (commencing with Section
WOOD SHAKES ❑
7000) al Dlvlelon 3 of the Business entl Professions Code, entl my license is In full torch entl
effeol.
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Lken9e Close !�— Llc. Number 7 � � 0./
WOOD SHINGLES
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OTHER (SPECIFY) (l ❑
DateLi_I6 Contreclar
'
OWNER -BUILDER DECLARATION
APR 16 1999
I hereby affirm that 1 em exempt from Me Contractors License law for the blbwirg reason.
PROPOSE
(Sec. 7031.5, Business, and Professions Cade: Any city or county which requires a permit to
construct, after, improve, demollsh, or repair any simcture, prlor to re issuance, also requires the
BUILT-UP ROOF
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
Ir(nC/
of Me Contractors Ucenw Law (Chapter B (commencing with Section 7000) of Division 3 of the
y
Business and Professions Code) or that he Is exempt therefrom and the basis for the alleged
ASPHALT SHINGLES
exemption. Any vlolahon of Section 7031.5 by any apolcant for a permit subjects Me applicant to
a civil penalty of not more than five hundred dollars (551X)).):
WOOD SHAKES
❑I,es owner of the property, or my employees with wages as Meir sole compensation, will do
the work, and the'structure Is not Intended or offered for able (Sec. 7044, Business and Proles-
sions Cade: The CorHrectore Ucanse Law does act apply to an amen of properly who builds or
WOOD SHINGLES
Droves thereon, and who does such work himself or through his awn employees, pro+Ned that
euch Improvements are not or offered for bele. however, the bulking or Improvement
Is lebe ,
within one year of completion,ill
the owner-bultoer will have the burden of Proving that he tllo
OTHER (SPECIFY)
t build urposetlon,
not bulltl or Improve for purpose of
. I] 1, are owner of the property, am exclueNely contracting with licensed contractors to construct
the project (Sec. 7044, Business and Pmfesslonh Code: The Contractors Llcense Law does not
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who builds or immc,,es thereon, and who contracts for such projects
with a wntrector(s) Ibense t pursuant to the ConirbchWs License law.
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 am exempt under Sec. ,B & P. C. for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury ane of the IollotWrg declaraten:
I have and will maintain a Certificate of Consent to seitansure for workers Compensation,
m prwltletl for by Section 3700 o1 Ma Labor Code, for the Parlor of the work for which this
permlt ue
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/ /✓W
/Al
Building O
.
of
have end will the elrf Workers f the work for Insurance, be required by Section 3700 s
the icor Code, for the pedormuKe of Me work for which tela Permit Is lesuetl. My Workers
Seismic
Compensation e�uretrxx carrier and Paltry number are:
Total
Ijaj
PERMITpdfH
RIZATI N
DATE
Carne C PolcyNoAAIII_Ia(S9'�3I
CERTIFICATE OF EXEMPTION FROM WORKERS'
�' j�6 ' f
COMPENSATION INSURANCE N.00
(This section need not be completed If the permit Is for one hundred dollars ($100) or ion.)
' I certlty that In the performance of the wWx for which this permit Is issued, I shelf not employ
All roofs shall . In Sped prior to any roofing material being
any person In mry manner so as to became subject to the Worrars' Compensation Lowe of Ceti-
forma.
Installed. If roof is installed without first obtaining an
Date Applicant
inspection, agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It, after making this Canlficete of Exernptlon, you should become
Applicant understands and will with all non point
PP coon I P y P
subject to the Workers' Compensation provisions of the Labor Cotle, you must forthwith compy
with such prwfelons or this Permit shapes beensd revoked.
Source regulations.
I cantly Met I have read this application and state that the above Information Is comeot.I agree
to comply with all city and county orcmatacas and state laws relating to bulking construction,end
All roo ovenngs to bec s"C° rbetter.
hereby euthodm representatives of this city to enter upon the ebv mntio
cened property for in-
spection purposes.
�//�
(We) agree to save, Incl mnRy and keep hermlase the City of Cupertino e Inst Ileblitles,
rncansequerx:e
jud iAlt, costs and expenses which may 1n any way accrue against said City
SIGNATURE P NT DATE
of 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
OFFICE COPY