R-5483 PERMI
VNUMB R R- 5483
APPLICATION FOR CITY OF CUPERTINO
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 LASTCALLED INSPECTION.
BUILDING ADDRESS / q
r02-4Z 4 p f-/t0 RESIDENTIAL_)�_COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
T YES ❑ If yes—I understand that a Class A
NAME /YQGY �i rr roof assembly is required.
I I NO ❑ Initial I.C.B.O.N
ADDRESS /ii 44S oj` W/ ✓ P1452e- ! �..o.taif% EXISTING ROOF COVERING
PHONE LH 08 6 —/ 72,:-, NUMBER OF EXISTING COVERINGS 33 SQ
CONTRACTOR'S /' �.,�
NAME SYS C�BI't-a'& Gt'�'^� TO BE REMOVED j�Sr"ot TO BE RETAINED -+�•
ADDRESS q TYPE OF ROOF COVERING
CITY&ZIP 907/
EXISTING
PHONE .Q BUILT-UP ROOF ❑
LICENSE
NUMBER 6 6 196 ASPHALT SHINGLES ❑ l�
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 0(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is in lull force and
effect B 6611996 WOOD SHINGLES ❑ 9
License Class Lic.Number i
Data OTHER(SPECIFY) ElOWNER--BUILDEBUILDE � P-�'�
R DECLARATION PROPOSED
hereby affirm that I am exempt from Co e; Any
License Law for 1.h axing anis t V%T` 'j"�
(Sec.7ct,alt Business and Profedemolish,
or rep it any Any city or county which requires requires permit to }ill J51' v E
sop IcarLaiter,Improve,tlemelia signed staement that he prior tnse i suance,pursuant els oprovithe BUILT-UP ROOF
applicant for such permit to ills a signed statement that he is licensed pursuant to the provisions
' of the Cs and Pro License Lew(Chapter h(commencing with Section 7000)of Division 3 of the Ec(� X997
Business and Professions Coda)or that he le exempt therefrom end the basis for the alleged ASPHALT SHINGL S DEt/
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars($500).): WOOD SHAKES
❑1,as owner of the property,or my employees with wages as their sole compensation.will do pV�—tea
the work,and the structure Is not intended or offered for sale Sec.7044,Business and Profen- B
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 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 Wilds or improves thereon.and who contracts for such projects
with acontexempt)under
Se pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS. CfT
❑1 em exempt untler Sac. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT EE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: 7 l
❑I have and will maintain a Certificate of Consent to salMnsure for Worker's Compensation, Building(...)
as for by Section 3700 of the Labor Code,for the performance of the work for which this
permitmit is is Issued. (/' S 6 U Seismic
❑I have and will maintain Worker's Compensation Insurance,as required by section 3700 01
the Labor Code,for the performance of the work for which this permit is issued.My Worker's / Total /L '0_
'Compensation Insurance carrier antl Polic number are:
Carrier(9704-412(9704-4(9704-412'— Ewe Jhs . Policy No. A"i 4"363�a PERMIT AUTHORIZATION DATE
CERT) CATS OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N /) �b n
(This section need not be completed it the permit Is for one hundred dollars($100)00)o Or less.) f,/
1 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 subject to the Workers'Compensation Laws of Cell. All roofs shall be inspected prior to any roofing material being
Cmia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,)agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Cade,you must forthwith comply
with such provisions ar this permit shall be deemed revoked. source regulations.
I certify that I 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 Allrings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes. /2 �6 _9
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities. /
�i�l
judgments,costs and expenses which may In any way accrue against said City in consequence SIG ATURE OFA L1CAN I DATE
of the granting of this permit.
1101, 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