R 5846 PERMIT R_ 5846
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408)777-9228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS Zd ) (tJt Q.
a♦ �, RESIDENTIAL�COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME )L �.�5'�/ ! i roof assernby is required.
NO Initial I.C.B.O.M
ADDRESS 2- I AIk,e-e, Ln , EXISTING ROOF COVERING
PHONE Z — O"J 1 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME � o
i ` TO BE REMOTO BE RETAINED
� wit Ruiz-=/zly VED
ADDRESS ^^� , r RTYPE OF ROOF COVERING
CITU&ZIP_f f lu gCii VP))4 1Pyi
EXISTING
PHONE ��5 3 BUILT-UP ROOF
NUMBER — O��" 3 ASPHALT SHINGLES
❑
USED CONT ACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES
7000)of Dlvlslon 3 at the Business and Professions Code,and my license le in lull force and
effect. 7 (�er Z. 3' 8 WOOD SHINGLES ❑
License Claea G 77 Lic.Number v
Dale / Contractor r Gx/�c/rT`^f/ OTHER(SPECIFY) ❑
OWNER BUILDER DECLARATION Tr�� PROPOSED
hereby affirm,Bu in that em exempt from the Contractor's License Lew for the following reason.
(Sec.construct,
It Business and demolish,
or re Code: Any city or county which requires a permit to
applicant orsuImprove,to file asigned statim ntructure,that he Is licenseor to Issuance,rsuant also requires the BUILT-UP ROOF
applicantforouch permit to flaw asignedr 9(co(commencing
it licensed 7000) Rothe provisions of
Busine. of the ss and tots License Law(Chapter h(commencing with om and 7000)of for the 3 of the
exemption,
entl violation of Code)or that he is exempt therefrom end the jbasisis ler me scant to ASPHALT.SHINGLES
e civil pen.Any f violation more
of Section 7031 S by any applicant for a permit subjects the applicant to
e civil penally of not more than flue hundred dollars($500).):
❑I,as owner of the property,or my employees with wages as that,sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for agile(Sec.7044,Business and Profes.
sions Code:The Commences License Lew does not apply to an owner of property who builds or WOOD SHINGLES E]Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-bullder will have the burden of proving that he did OTHER SPECIFY
not build or Improve for purpose of ails). (SPECIFY) ❑
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR. INSTALLATION SPECS.
r]I am exempt under Sec. ,B$P.C.for this reason
OwnerData
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following Seung tlure for P A
❑ have and will maintain 37a of the
ate bof Consent toeperforma far of
Worker's Compensation,which
his 1'� ® Blllldln
as mit Is Is for by Section 3700 of iha Labor Code,for the performance of ins work for which Ihla g
in
permit la leaned. Seismic
❑ have and will the pert Worker's Compensation the work
for Insurance,as required u Section 3700's Fa 6 O �(Yj
the Labor Coda,for nc performance of the work for which this permit le Issued.My Worker'snl 4l V *5 Total
Compensation Insurance carrier end Polley number are. 7 Go laA
Carrier Policy No.5 Tr �7 1_� - 1 LPERMIT�AUTHORIZATION DATE
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(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 shall not employ
any person In any manner so as to became subject to the Workers'Compensation Laws of Call- All roofs shall be inspected prior to any roofing mat ial being
forme. 7installed. If a roof is installed without first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Code,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 I have read this application and elate that the above Information is corraet.I agree li
to comply with ell city and county ordinances and state laws relating to building const ruction,and All roof coverings to be class'i or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In. s�
speedo)purposes. , IJ
(We)agree to gave,Intlamnlfy and keep harmless the City of Cupertino against IIebIIlllee,
• judgments,nista and expenses which may In any way accrue against said Of In consequence
of the granting of this permit. SIGNATURE OF APPLICANT
DATE
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