99110142 7
APPLICATION FOR CITY OF CUPERTINO
REROOF PERMIT
INSPECTION DlvlsloN
ON
(406)777-3226 IT PIKES IF WORK IS NOT STARTED
80 M S 1WDAYS OF PERMIT ISSUANCE OR
1
1 W DAVS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS
3 RESIDENTIAL COMMERCIAL OTHER_
OWNER'S HAZARDOUS FIRE AIR
YES ❑ H yea-I understand That a Cless A
NAME 1P,�''Y7// Sv 1�7P r NO E] roof assembly is required.
thel I.C.B.O.B
ADDRESS �7173� 5�4�� � EXISTING ROOF COVERING
PHONE p NUMBER OF EXISTING COVERINGS ---/
CONTRACT
NAME_ ,��//SC,0 �� LV\g TO BE REMOVED TO E RETAINED
/
z
ADDRESS �
—� TYPE OF ROaCOVERINQ
CITYazIP ZZ9� �hcC✓u Av
/ Q
MISTING
PHONECA� �C43 CYO ' BUILT-UP ROOF
LICENSE
NUMBER S 36 ASPHALT SHINGLES
LICENSED CONTRACTORS DECIARAPON
I hereby affirm that I am licensed under provisions of Chapter B(canmencing with Section " WOOD SHAKES
7")of Division 3 of the Busiross entl Professions Cade,erd my license a In fue force end
eHe
WOOD SHINGLES ❑
License Clew � 2� Uc.Number
Date 11-2--Z'- 9? Contras0, A*451�42- OTHER(SPECIFY) ❑
OWNER-BUILDER DECIA 'I �— PROPOSED
.701. ,Bu that am exempt from the Contractor's uceree Lew for Ota following a reason. D
(Sec.]031.5,Business and Professions Coda: Any city or county which requires require.permit toconstQ
applic nt,ar er,su improve,demoto file s or rd sta eny mentrmet e,pear to les Issuance,also Meprovithe BUILT-UP ROOF
of me Contractors
tr such permit to file a signed statement that he is licensed Sectio pursuant to the provisions ❑of the mis and for lUaense Lew Kepler h Is oxorrml I with Salted the three
a Dfor me 3 of the 1
• Business entl viciatalons Code)or that he le exempt therefrom and the bests toe the alleged ASPHALT SH NG S O`1 Q ,g99
a dyll en.A ofnetm re Seddon 703dred dotty eppllrantfor ePermit subjects the applicant to ,\ V 21
a dull penally of not more than five hundred dollars(5500).1: 1,
❑I,asowneral the proper(y,ormyempbyeeawith wages as their sole compensation,wllldo WOOD SHAKES �]
Ota work,and the stncture Is not Intended or Offered for sale(Sec.7044,Busincas and Profen. - \
ekns Code:The Contractors License Lew does not applyto an owner of property who balks or WOOD SHINGLES
improves thereon,entl who does such work himself or through his own employees,pp ded thiol B —such improvements are not Intended or offered for sale.If,however,the building or hnprovement Y
Is sold within one year of completion,the owner-bullder will have the burden of proving that he did SPECIFY
not build or Improve for purpose of sae.). OTHER(SPECIFY) ❑
❑1,as owner of the property,am exclusively coatracl4q with licensed contractors to construct
fine project(Sec.7044,Business and Prolessions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner ol proporty who bulltls or improves thereon,and who contracts for such praleds -
wuh a cantractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
CII em exempt under Sec. ,B 6 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
1 hereby affirm under penalty of perjury cm of the following declaration:
1 have and will maintain a Cenlflcate of Consant to self-Insure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for Ne performance of the work for which thus g
Permit Is Issued. Seismic
have and will maintain Workers Compensation Insurance,as required by Seclen 37M of
the Code,for the performance of Ne work for which this permit 6 Issued.My Workers p
Compensetlon Insurance carder en Pollky nynber ere: /- 7�J 9L0 7 ��� �� Total '
Carder Z rl t• -.1 J' lcyNo.SG2D(1r37, - 06 PERMIT/AUTHORIZATION DATE
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C{]
(This section need not a completed If the permit Is for one hundred dolens($1D0)or IeeaJ //—�L�
1 certify let In the performance of the work far which M15 permit Is issued,1 shell not employ
any person In any manner so as to became subject to the Workmi'Compensation Laws of Call- All roofs shall be inspected prior to any roofing material being
farad.. installed. If a roof is installed without first obtaining an
Data 1/-��r1 Applicant oIEya Inspection,I agree to remove all new materials for Inspection.
NOTsubject ltoE a Workers'TO ANT: It,after Comiseasmain prkwlsions of the LaborCode,ymu must fwintl Applicant understands and will comply with all non point
with such provisions or this permit shall a doomed revoked. source regulations.
1 ce"Ify that I have read this apptiration and state that the above Information is correct.I agree
to comply with all dry and county atllnaroes end state laws refining to building construction,am All roof coverings to class�or better.
hereby authorize representatives of this clty to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,Indemnity and keep harmleea the City of Cupertino ageimat Ileblitmi, AaJ741 147
judgments,costs and expenses which may m any way accrue agelnst said City In consequence
of to granting of this peman. - SIGN E AP DATE
• PRE-INSPECTION: PLYWOOD: 19-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
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