99090085 3S- 7 - 0-3 -0 Y q67 OqOil
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)X7-3228 .PERMIT EXPIRES IF WORN IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS
D32 G/UUT C/0'CL
O �� RESIDENTIAL � COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ s A
NAME anoblyis�red.
fNO ❑ Inlhal I.C.B.O.R
ADDRESS /05�7�C> 57 �0r11G6' IR U� F�XXI51ING ROOF COVERING
PHONE 2S 25-B6 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ERNG
CITY a ZIP
EXISTING
PHONE BUILT-UP ROOF /V
LICENSE T❑�
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES 17
7000)of Division 3 of the Business and Profaul Coca,and my license Is in lull force and
effect WOOD SHINGlwS
Lbeme Class Lk.Number
Date contractor OTHER(SPECII L/� ❑ rl):
Opt from Me ConRDECLLicensN PROPOSED SEP •I(J r
I hereby affirm that 1 an eProfes ions Ne e: Any
License Lew for the regulate
ag reason. 1 n• 1999 L� I
(Sec.]1731.5,Business ark Professions Coda: Arty city or omnry which requires a uir s to r
construct,or ,such
Improve.to fildemolish,or rePairerry structure,e,prior to Its issuance,to theequires the BUILT-UP ROOF
of Me for etch permit to file a signed stareo-antmm that he Islicensed!Sectio WXX)of to theori 3 ofone
of the Contractors and License Lew(Chepull B is ore enclrrg with Section Metal for to 3 0l the
exampss entl vicha sloes Code)or 31 he is exempt therefrom ark Ne basis for the allegedanto ASPHALT SHINEiI $
ereVillaw Arryf ffert o of Ban five hundred
by arty applicant for a permit wbjede the eppfYant to
e a,ss{y'pas"of oft more Nen Ilse hundred defers ❑
py,as and!
or the structure
property,is n t I my empbreffered crepes as theirw,compensation,will e. WOOD SHAKES
t rid,and the slmcNre ie not Intended or offered for sale(Sec.]094,Business acid Prolee-
sims Code:The Cantmctors Ucenw.Law wes not appy to an owner of property who bulks or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that -
such Improvements are not Intended or offered for sola.If,however,she bilding or Improvemanl
Is sold within one year of completion,the canner-bolder will have the burden of proving that he del OTHER(SPECIFY)
net cowl m Improve for purpose of ee7e.). El
❑I,as owner of the property,em excivavely,contracting with licensed contractors to constrol
the project(Sec.7044,Business and Professions Code:The Contractors Lfoense Lew dose not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a ccotrector(e)licensed pursuant to the Contractors License law. PROVIDE MFGR.INSTALLATION SPECS.
C]I em exempt under Sec. ,B 8 P.C.lar this reason
Do'
woR ER'sCOMPENsnnoNOECLAA . APPLICATION DATE VALUATION PERMIT FEE
�I hereby affirm under penalty of perjury me of the following daeareflon: -
❑the"and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, - - Build In
u provided for by Section 3700 of the Labor Code,for the perlormarrce of the work for wNch ihls ^•��(/' g
theporut LaierCwove for
1
❑ ve ( !fo Seismic
I haend will maintain Workers Compensation Insurance,as required by Sectlon 3700 of /
the Labor code,for the performance of the far which this permit Is Issuetl.My Worker s
Compensation Insurance terrier and Policy number are Total
Careen Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NC[]
(This section need not be completed it the permit Is for one hundred dollars(51 00)or leas.)
I certify that In the performance a the work for which this permit U issued. shell rgf amp for•
eery person In any manner w as to become subject to the Workers'Compensation laws of cavi- All roofs Shall be itispected prior to any roofing material being
formla. installed. If a roof is installed without first obtaining an
Date T1iiiApplicant Al�9r - inspection,I agree to remove all new materials for inspection.
NOTICff TO APPucANf: If,after making 1 Cal Exemption,you should b75t.Uma ,applicant understands and will comply with all non point
subject to the Workers'Compensation provislons of the Lobar Code,you must forthwith comply
with such provlalons or this penrut shall be doomed revoke 1. source regulations.
1 cerey that I have reed the appllcatbn end were that the abme Information Is correct I agree
to campy with all city ark county Ordinances and state laws relating to bulldog conswabnand All roof coverings to be classoor better.
hereby authorize representatives of this dry to enter upon the above-mentioned Property for In. ,�7s
spa purposes,
(We)
agree to save,I and keep harmless ice Cly of Cupertino against lieblitioe,
Judgments,costs and expeases,enses which may In any way state against said Gry In cauequence SIGNATURE OF APPLICANT DA
of the granting of this permit.
ARE-INSPECTION: PLYWOOD: IN-PROGRESS:
IINSP. 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
s
OFFICE COPY