R-5134 ~ PERMIT R_ 5134
APPLICATION FOR CITY OF CUPERTINO NUMBER
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 IASTCALLED INSPECTION.
BUILDING ADDRESS / P�f j
10 3 T 6 I �� Y RESIDENTIAL ✓` COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
O�—fj qOA IEI"A�D ���r) YES ❑ Ifyes—Imbly is required. Class
NAME T H l� F'1 roof assembly Is requiretl.
NO Initial— LC.B.O.q
ADDRESS (m 3 G A M.1 °D CT•• EXISTING ROOF COVERING
PHONE Z5 ' NUMBER OF EXISTING COVERINGS ,,��1�
CONTRACTOR'S� O�J — /' TO BE REMOVED 30 TraRETAINED
NAME KB/�AISSAM(:8 4 Q- ific, Co • ! �NC .
TYPE OF ROOF COVERING
CIT�ZP ZZ9Z Lrti�6�� A\)i_ S�' �51Z5
/�,.,�•�\ EXISTING
PHONE I—fSi�^ J �//�mb�� BUILT-UP ROOFLICENSE
❑
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby affirm that I em licensed under Professions
of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professlons Cotle,and my license Is In full torte end
effect, WOOD SHINGLES
/n CJ 5 ❑ /V\�
License Cl a M � Llc.Number
Date —014 Contractor�'DAiS'$A/D(b �OFVOTHER(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 Contractors License Law(Chapter 9(commencing with Section 700()of Dlvlsion 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).): WOOD SHAKES E]I,as owner of the property,or my employees with wages as their sole compensation,wl II do
the work,and the structure Is not Intended or offered for safe(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 El
thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build 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.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractors License Law. PROVIDE MFGR. INSTALLATION SPECS.
❑1 am exempt under Sac. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT F
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: PA w -
I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, I"A 1
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 6/ 7 �/ //�/�
perm) Issued ��� / / ( Seismic
have end will maintain Workers Compensation Insurance,as required by Section 3700 of N
t r Cotle,for the performance of the work for which this permit Is Issued.My Workers �� Total
Compensation Insurance carrier and Policy number are: UP D
Carrler� COMfd ") PollcyNo. ' -PI;FI 1 AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed if the permit Is for one hundred dollars($100)or 1888.)
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any person In any manner so as to become 34blogi to the worker,'Compensation Lewis of call- All roofs shall be inspected prior to any roofing material being
fornia. '/� i installed. If a roof is installed without first obtaining an
Data ApplicantAr{/ / L.+•{�r inspection,I agree to remove all new materials for inspection.
NOTsubject lto me wok rsCC ComT.pensation tion provisionio len 1L bor ofode,you must forthwith comply Applicant understands and will comply 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.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All of coverings to be class"C"or better.
herebyauthorizepure lie representatives of this city to anter upon the above-mentioned property for in
ep(We) purposes. /�4�
(We)agree s save,expenses
Indemnify and keep harmless yway iha City ai Cupertino against Ilabile—, Z� (•
judgments,costa and expenses which may In any way accrue against said City In consequence SIGNATURE OF APPLICANT DATE
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY