R 5432 ~ PERMIT R,
APPLICATION FOR CITY OF CUPERTINO NUMBER 5 4 3 2
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1 B DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS/
10500 a /�10r-y l 6 ) U!� RESIDENTIAL ^ COMMERCIAI OTHER
OWNER'S j�a.-, �! HAZARDOUS FIRE AREA '
�-�8l / � C g'° e�...) er YES ❑ 11 yoas understand that a Class A
NAME - roof assembly is required.
NO Initial I.C.B.O.#
ADDRPQQ /D �3z5 o' � �� EXISTING ROOF COVERING
PHONE �vv- ao73 NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S �^•A / r�� TO BE REMOVED TO BE RETAINED
NAME:: /1 1+-4 - % /I..UOT(nq -
ADDRESS /i1 n�.r..L(,� / n .�,P J v TYPE OF ROOF COVERINCg
CITY&ZIP / I' lJ (�1 1,a l EXISTING
PHONE BUILT-UP ROOF
LICENSE / _ r�_
NUMBER (fJ ���J ASPHALT SHINGLES s��s
LICENSED CONTRACTORS DECLARATION ' —
1 hereby affirm that I em licensed under provisions of Chapter B(commencing with Sects WOOD SHAKES 1�Y1*'
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect
WOOD SHINGLES ❑
License CI a Lie.Number P p B
Date Contractor OTHER(SPECIFY). W ❑
OWNER-BUILDER DECLARATION PROPOSED APR
hereby affirm that I am exempt from the Contractors License Law for the following Lail. 9
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to + �essuu
construct,alter.Improve,demolish,or repair any structure,prior to its Issuance,also requires the BUILT-UP ROO" ❑
applicant for such Permit to Ills a signed r statement that g le h Section pursuant to the provisions of th Uf• Vt1r Cr(1 II�
al the Color such License Lew(Cheers (commencing is licensed
Secld pursuant nt o the 3 of the L)
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 dollare($500).):
01,as owner of the property,or my employees with wages as their able compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles-
alone Code:The Contractors 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 not Intended or offered for sale.II,however,the building or Improvement
to sold within one year of completion,the owner-builder will have the burden of proving that he dm OTHER(SPECIFY) El
bulld or Improve for purpose of sale.).
01,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Coda:The Contractors License Law does 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 contrectons)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
01 am exempt under Sec. ,B&P.C.for this reason
Owner Dale
WORKER'S COMPENSATION DECLARATION (APPLICATION DATE VALUATION PERMIT FEE
"
i hereby
have and under penalty of pecate one of the following declaration:
for Workers❑ have entl will maintain
37 a Certificate of Consent to eperfor a for Workers Compensation, /� Buildin
ee provl etl for by section 3700 of the Labor Coda,for the performance at the work for which this IT�I �^.��� g /
perms Issued. q ff (,,,J� r � $eISR11C
I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performs ce of the work for which this permit Is Issued.My Workers Total
Compen��njn 'bran meted Policy number are:
carder "-^ Policy NO � I PERMIT AUTHORIZATION E
CERTIFICAT DE
COMPENSATION T EN EXEMPTION
ATION INSURANCE I V I /
OFE EMPTISU FROM WORKERS'RANCE N,C[]
(This section need not be completed It the permit Is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit Is Issued,1 shall not em loy
any person In any manner so as to become subject to the Workers'Compensation Laws of gall. All roofs shall be inspected prior to any roofing material being
fords installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: 11,after making this Certificate of Exemption,you should become Applicant understands and will comply subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP ply with all non point
with such provisions or this permit shall be deemed revoked. source regulations.
I certify that l have read this application and state that the above Information Is correct.l agree
to comply with all city and county ordinances and state laws relating to building construction,entl Al roof coverin to be class"C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned proper,,for In-
spection purposes. I Ill
lWe)ogre to save,expenses which and keep harmless the Clry ai Cupertino said City a h con flabllence
judgmelts,costa and e,Indemnity a which may In any way she City y of Ct geld Clty 4n consequence
of the granting of this permit. GNAT] R APPLICANT OAT
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
OFFICE COPY '