R-5408J
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PERMIT R— 5408
APPLICATION FOR CITY OF CUPERTINO
p INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)%%% -3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNS Sf— -
HAZARDOUS FIRE AREA
YES ❑ Ifyess Iunderstandthat. Class A
NAME_( IGO
roof assembly is required.
Imgal LC.B.O.#
EXISTING ROOF COVERING
'1
NUMBER OF EXISTING COVERINGS
PHONE
��
CONTRACT R'S
v
'/�!�/L!
TO BE REMOVED TO BE RETAINED
NAME V�l��� 1��_ J�I�
TYPE OF ROOF COVERING
_
ADDRESS rte) / /L/�,�,��
CITY&ZIP /� (' �' L�(A - ' `a'04e
.
EXISTING
—io
Cl �
PHONE 7�� !S%
BUILT -UP ROOF ❑
_%4X
NUMBER
ASPHALT SHINGLES (�
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
WOOD SHAKES ❑
7000) of Division 3 of the Business and Professions Coda, and my license Is In full force and
effect
Class � Lic. Number
WOOD SHINGLES ❑
License
OTHER (SPECIFY) ❑
Date - -`;c/// — T CBUIUDE ��,N
OWNER- BUILDER CL `!T7"
PROPOSED
that am exempt from the Contractor's License Law for the following reason.
License hereby
"
, Bu Code: Any city or county which requires a permit to
(Sec. 70315, Business and Professions
rep any Issuance, also the
BUILT -UP ROOF
is license to
applicant for each permit to flaw a signed statement that pursuant to the provisions
applicant for to file a Signed
g with of 3 of the
o the Contractors License Lew (Chaplet 9 (commencing with Section 7000)
Q
Business and Professions Code) or that he a exempt therefrom and the basis ote
basis for the
ASPHALT SHINGLE$
Su
by any applicant for a permit subjects the applicant to
exemption. Any violation of foe scant to
a civil penalty than hundred ):
not more than floe hundred dollars (h
WOOD SHAKES Q�
wag
❑ I^ as owner of the property, or employees with wages as their sale compensation, will
a
to ded for sale (Sea Business and s.
the work, and the structure Is no Intended ores
TheContractor' sLicenseLewdoesnotapplytoanownerofployetywhobuildsor
not owner of builds o-
WOOD SHINGLES ❑
improCode:
improves thrown, and who does such work himself or through own employees, provided that
offered Improvement
are not offered for sear. ev building or Improvement
such improvements however, the
ill
th builderwillhavetheburdenofprovingthathedid
within one y completion, en pr
ntbuild
OTHER (SPECIFY) ❑
or prove forpurpostheowner-
not build or Improve for purpose of sale.).
1, 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.
apply to an owner of property who builds or improves thereon, and who contracts for such projects
with a contrectogs) licensed pursuant to the Contractor's License Law.
PROVIDE MFGR. INSTALLATION SPECS.
I] 1 am exempt under Sec. ,B & P. C. for this reason
Owner Date
APPLIVAt"ION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
,yt�^�l
I hereby affirm undo, penalty of perjury one of the following declaration:
❑ I have and will maintain a Certificate of Consent to self- Insure for Worker's Compensation,
1', lx"�
b>
Buildin
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
i
SEp
per mIll a leBUed.
I,Uy/���
Nv` ( / �
$eism1
va antl will maintain Worker's Compensation Insurance, as required by Section 3700 of
the Labor Code, for the the for which this Is Issued. My Worker's
^�.� VV��HI
V�
performance of work permit
Cj�1 r
Total
Compensatlo rents arrier a olicy nyfnbar are:
��%
Carrier ✓ I Policy NP/
PERMIT AUTHORIZATION
rRATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE IN Co
(This section need not be completed If 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, I shell not employ
any person In any manner so as to become subject to the Workers' Compensation Laws of Cell-
All roots Mall btfinspected prior to any roofing rhaterial being
fornia,
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
Certificate of Exemption, must
dbcomply
Applicant understands and wi omply with all non point
subject toEthe Workers' Compensation provisionis of Code, forthwith
with such provisions or this permit shall be deemed revoked.
Source regulations. ^
I certify that I have road this application and state that the above information Is correct. I agree
' 'C"
comply with city and county construction, and
to comply with all city and county ordinances and state laws relating to
to building c
All roof cove or better.
of this city to enter upon the wing
hereby anti n property far in-
spection purposes.
IWe) agree to save, indemnity and keep harmless the City of Cupertino against liabilities,
judgments, costs and expanses which may in any way accrue against said City In consequence
T
OF APPLICANT ATE
of the granting of this 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
OFFICE COPY