991100273Z� /7
APPLICATION FOR CITY OF CUPERTiNO
4 a ap"
INSPECTION DIVISION -
REROOF PERMIT (408)777-3228 PERMIT 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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:77a-5-6 `'''
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RESIDENTIAL COMMERCIAL OTHER
OWNERS
HAZARDOUS FIRE AREA
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A tL AS
YES ❑ n yes. I understand that. class A
NAME �L/1ie /\
roof assembly is required.
NO ❑ Initial I.C.B.O. p
EXISTING ROOF COVERING
1V 3U O 0/ AYE
ADDRESS / r
PHONE
NUMBER OF EXISTING COVERINGS
CONTRALTO 'GS ,,r---�J��
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NAME 6,4' \_l /` DC O�
TO BE REMOVED TO BE RETAINED
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ADDRESS /?00 Cr �^ � n . ,_/—Q � IO `� �IV
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Jam/
_ TYPE
cin a zI/P ! 7- a��/ � U
EXISTING '
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-PHONE`C.O=,�C7`5///��/�`�
BUILT-UP ROOF/ ���
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6
NI
UMBER T6 7i/ -
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed water provisions of Chapter B (commencing with Section
7000) of DINSIcn 3 of the Business and Professions Code, and my, license Is In full force anal
WOOD SHAKES D
effed. _
Ucense C
WOOD SHINGLES Novo- 4 1999 D
a Lb. Number
Det comrepmr
OTHER (SPECIFY) ❑
PROPOSED B
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec. 7031 5, Business and Professions Coda: Any city or county which requires a permit to
Y
.construct, alter, improve,demolish, or repair any structure, prior to its Issuance, also requires the
BUILT-UP ROOF
applicant for such permit to file a Signed statement that he Is Real pursuant to the provisions
of the Contractor's License Law (Chapter B (commencing with Section ]0(0) of Division 3 of the
Business and Professions Code) or that he Is exempt therefrom and �thsue basis for �theIalleged
tt
e dull penalty of net more than lire huntlretl tlollere (s
exemption. Myviolationof Section ]03dr byally appl a�m.L'f9'r
SHINGLE$ ❑
❑ I, es owner of the ar my employees with ges es Mif n II
KE$ ❑
property,
the work. entl the Structure is not intended or oflored I eal�(Sec fe
�Yl
stns Code: The Contredpr6 Ucerse Lew does not app y to en owner of property who Wilds or
Improves thereon, and who does such work el Sell or througo Sew
such improvements we hot Intended or offered for sale. If,
SHINGLES ❑
.
is sold within one year of completion, the owner -builder will havb7"Ihe7 fpr
(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑1, as owner of the property, em exclusively contra rg wMiTeR can dors tocondrud
Me project (Sec. 7044, Business and Profeswons Code: Thi Con�l�rreen^rp L Le oe
apply to an owner of property who poll or Improves th{rsbb^ Q,_A n preIN
with a contractar(e) kbensetl to the Contreat be �M=
B.O. REPORT NO.
I All
pursuant sa
L�.
GR. INSTALLATION SPECS.
❑ 1 am exempt under Sel
Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury, one of Ne following declaration:
❑ 1 have end will maintain a Certificate d Consent to self -insure far Workers Compensation,
Buildin g
as provbed for by Section 3700 of the Labor Coda, for the Performance of the work for which MIS
permit is leered.
❑ 1 hove and will maintainprt Worker's Compensation as requhe0 by Section 3
C / f /
.-1 !!! VVV
Seismic
Hoe Labor Cdtle, for performance W Hie work w1hichrvco,
work which Mb permit b Issued. My WOM1z1re
Worker's 's
nc r a
Compensation Insurance canter end Policy number are:
Total /1 —211
Canner Policy, No.
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM YORKERS'
COMPENSATION INSURANCE
(Thio eactbn need net be completed it the permit b for one hundred dollars ($100) or leas.)
100) o
I county Chet In Me performance of the work la which this permit le Las shell not employ
All roofs shall be inspected prior to any roofing material being
any person in any manner an as to become Subject To orkere' cin ensat n m I.
fen'b
installed. If a roof is installed without first obtaining an
Daryl—/ Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPUC4rr: If, after making I&Vbat1lri d Exam sheam
Subject to the Workers' Compensation provisions of the Labor Code St lonhwiM comply
Applicant understands and will comply with all non point
PP P Y
MM Such provisions or this perel Shell be deemed rewked.
source regulations.
I cenity that I have read this application and state Met The coal Information Is correct. I agree
to comply with all city and county ordinances and State laws relating to building construction, and
All roof Coverings to be r atter
hereby authorize representatives of MIs city to enter upon the above mentloned property for in-
spectlon purposes.
J
(We) agree to Save, indemnity and keep harmless the City of Cupertino against IIabllnes,
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judgmante, cods and expenses which may In any way accrue against said City In consequence
-
I APP NT I DATE
ol the grain of MIs 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION