99100142 33 c> 3 10 0
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APPLICATION FOR CITY of CUPERTINO
INSPECTION DIVISION
REROOF PERMIT (408)T77-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1W DAYS OF PERMIT ISSUANCE OR
1 W DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/. ,/D? � "Q �/I RESIDENTIAL COMMERCIAL - OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME ✓ /��.fD YES ❑ If yes-I unticrstend that a Class A
roof assembly is required.
NO ❑ - Initi LC.B.O.N
ADDRESS
/93Op �G�OI'6 �ps/. EXISTING ROOF COVERING
�(/ /
PHONE ��� of S� /�/s NUMBER OF EXISTING COVERINGS
CONTRACT 'SA/
Al/
�vc�U./ �6 A TO BE REMOVED E RETAINED
�! �/
ADDRESs 7 -yc/ A -� TYPE OF RO 1
CITY&ZIP ylo7fni.1/ til[ /�'l�P, i�b+;O,fq?✓CtJC�/4I . //
EXISTING /O
PHONE 3
- Sd 3 9s/a9 BUILT-UP ROOF El / / 9
LICENSE
,3 ElNUMBER SD7'sASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm Nat I am licensed under proAelons of Chapter B(commencing with Settlor WOOD SHAKES
7")of Dlkidon 3 of the Business and Professions Cade,and my licenv Isin full force end
effect.
/n7 WOOD SHINGLES ❑
License Cleo`- -3 Lk.Number .Sen" '�Y3
Data Contractor 3- 3y'. r'> /" OTHER (SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Business and Protaalons Code: Any city or county which requires a permit to
construct,alter,lmproke,demdish,or repair only structure,Prior to Its Issuance,also requires the - BUILT-UP ROOF Elapplicant for such Permit to file a signed statement that he Is licensed pursuant to the provlabnM
of Ne Contractors License Lew(Chapter 0(cominverei g MN Section]000)of Division 3 Of Ne -
Business and Professions Code)or Net he is exempt therefrom antl rhe Mals for the alleged ASPHALT SHINGLES ❑
exempilon.Any violation of Section 7031.5 by any applicant for a permit sublimes the epPlkent to
a cIWI Penalty of not more than five hundred deters(5500).1:
❑1,an owner of the property,or my employees with wages as their sole compenvtitn,will do WOOD SHAKES
the work,and Ne structure le not Intended or offered for Mala(Sec.7066,Business and Pro1ae-
slons Code: The Contractors License Law does not apply to an owmer of property who builds or WOOD SHINGLES
` Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intended a offered for sale.If,however,the bulldlrg or Improvement
I. to within erre year of completion,the owner-budder will have the burden of proving that ho did OTHER(SPECIFY) El
build or improve for purpose of sale.).
❑I,as owner of the property,am exclusivady contracting with licensed contractors to construct
Ne project(Sec.7066,Business and Professions Code:The Contractors Ucerree Law does rot PROVIDE I.C.B.O.REPORT NO. '
apply to an owner of property who builds or Improves theroon,and who contracts for such project.
with a contract«(s)licensed pursuant to the Convectors Ucenv Law. PROVIDE MFGR.INSTALLATION SPECS.
E]I am exempt under Sec. ,B&P.C.for this reason
°%ma' Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under Penalty of perjury one of the following declaration:
I have and will maintain a Certificate of Consent to self-lnsure for Workers Compensatlon, Building
as provided for by Sectlon 3700 of the Latour Code,for the performaroe of Ne work for which this
permlt is issued.
❑I have antl will maintain Workers Com tenvtkn Insurance,as required by Section 37a of D 0 Seismic
the Labor Code,for the pedormance of the wxxk for which Me permit Is Issued,My Workere
re
CompeatInlon mrXre canter end Policy nuber are: / Total/
Z Q
Carrier r/d mPolicy No. if Z o ?MO PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' 9
COMPENSATION INSURANCE N.CQ
(This section need not be completetl If the permit Is for one hundred col($100)or las..)
I cortlty that in the performance of the work for which this Permit Is Issued.I shall not employ
any personIna manner so es to become subject to the Workers'compensation Laws of call. - All roofs shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPUCANT: If,aper rreklng this Certificate of Exemption,you should become ,applicant understands and will comply with all non point
subject to the Workers'CompenaW tbn provisional Ne Labor Cade,you must forthwith comply
with such provisions or Nis permit stall the,deemed revoked. Source regulations.
I coldly that I have read Nis application and state Mitt the stooks Inforratbn is caned.I agree
to comply with all cry and county ordinances and state lean retailing to building construction,and All roof OVeri S to be class dor better.
hereby authorize representatives of this city to enter upon the abovamentioned property for N-' /�O /
VIM p
sp agree sae. ` /d/ //
9/
(Ws)agree to ave,indemnify and keep herniae the City of Cupertino against liabilities,, �ti vHis
judgments,costs end expanses which may in any way accrue against sold City In consequence SIGNATOR OF APPLICANT DATE
of the 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