R 5493 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5493
. INSPECTION DIVISION PERMIT EXPIRATION
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.
lie BUILDING ADDRESS
103lq
0 LVN 5tu0 r141 0 r.
q J n I U RESIDENTIAL_A COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class A
NAME-LI'I°51 roof assembly is required.
r NO ❑ Initial I.C.B.O.N
ADDRESS S a-V%,-,V., EXISTING ROOF COVERING
PHONE (_4'1 8 --, - .�. !.'; SC SC NUMBER OF EXISTING COVERINGS _/
CONTRACTOR'S -
CO S d 0 ,( 62 _ _ / '-n TO BE REMOVED X TO BE RETAINED
NAME (lws+ � �C.P�LJ I' ^ ' - - -- -
CITY a ZIP P D x -7�,�p CfA4� �J�3 TYPE OF ROOF COVERING
EXISTING
PHONP (4 d K BUILT-UP ROOF ❑
LICENSE ` .-L II ASPHALT SHINGLES ❑ J
NUMBER �K _Dy'y21.,
LICENSEO CONTRACTORS DECLARATION
I hereby affirm that I am Ilcensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
Cleanse Class
[�-Q 3 42 WOOD SHINGLES ❑
t^ 3 9 Lic.Number T �
Date Contractor OTHER(SPECIFY) ❑ ��
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
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 licensed pursuant to the provisions
of the Contractor's License Law(Chapter 8(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).):
C]1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Code: The Contractor's License Law does not apply to an owner 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 of not completion,or owner-builder for seer.ill however,the en of r or Improvement (SPECIFY) C'n
Is sold not or Improve for purpolheowner-builderwill have the burden of proving that he did OTHER SPECIFY
not bulltl or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO. Y'✓ OI
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(e)licensed pursuant to the Contractor's License Lew. PROVIDE Ill INSTALLATION SPECS.
❑1 am exempt under Be- ,B 8 P.C for this reason
Owner
WORKER'S COMPENSATION DECLARATION ale 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 sell-Insure for Worker's Compensation, Building r �r
r permit Is Is for by Section 3700 of the Labor Code,for the Performance of the work for which this /� O �7 /� �� T
permit Is have ( V Seismic i,y0
❑ have and wlli maltreat Worker's Compensation Insurance,as required u Section 3700's Ire'
the Labor Code,for the performance of the work for which this permit le leaurtl.My Worker's
-. camps n(�ge,�tl�on,InQsuran�ce c,�a.r�rier and Policy number are: I 'r'Kvq"'ralY' Qt ?
Carrier n Policy No.lJR71 ►137 a'1ti PERMIT AUTHORIZATION PAT
CERTIFICATI32 OF EXEMPTION FROM WORKERS' 14C-
COMPENSATION INSURANCE N C❑ LM11 I�D �(This section need er or ante of th If the permit Is for one rmit is I sued,dollars I(Salo)or less.) I `7 � A T 0 /I dertity lhal In iha pedormence of Ili°work for which Ihis permit is IssueQ I shell not employ any person In any manner so as to become subject to the Workers'Compensation Laws of Cell. All roots shall be irispected prior +aalln tarlal being
f°`ma. installed. If a roof is installed without first olitalAlng all -
Date Applicant inspection,i agree to remove all new materials for inspection.
NOTICE subject to the OWorrkereCC 11,after provisions Certificate of
Cape,Exemption,
ou must forthwith comply Applicant understands and will comply with all non point
with such provisions or they permit shalgbe deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against Ilablllties,
,u
If coats and expenses which may in any way accrue against said City In consequence
of the granting of this permit. SIGNATURE OF APPLICANT DATE
.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. ')ATE INSP. DATF INSP. DATF
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. nATE INSP. DATF INSP. DATF
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY -