R 5369 PERMIT
APPLICATION FOR CITY OF CUPERTINo
NUMBER R_ '5369 '
REROOF PERMIT INSPECTION DIVISION. PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS r //�•.
ZZo3� 3�jj'�c RESIDENTIAL f COMMERCIAL OTHER
OWNER's / - HAZARDOUS FIRE AREA
NAME v'e't h "v #W `�4'�'�/ �k'f t YES ❑ Ii yea—1 understand that a Class A
—� ' NO roof assembly is required.
Q�� ❑ Initial LC.B.O.#
ADDRESS— � �✓ •- —'�7E'F^4/.
EXISTING ROOF COVERING '
PHONE ZJ NUMBER OF EXISTING COVERINGS -
CONTRACTOR'S
NAME L �b�/,y�y TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP—
EXISTING
PHONE 9z`f fflr-'� _ BUILT-UP ROOF ❑ -
LICENSE
NUMBER 7z fy,9 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 Code,and my license Is In full force and
effect.
/n•_ 7Z7�9 WOOD SHINGLES ❑
License Class `� Lia Number - -
Dere o'ba ContractorR �' �a�/� OTHER(SPECIFY) ID
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Lew for the following reason.
(Sac.7031.5,Business and Professions Code: Any city or county which requires a ermif to
construct,alter.Improve,demolish,or repair any structure,prior to Its issuance, eo regmras ROOF ❑ 7-
applicant for such permit to file a signed statement that he Is licensed pursuant 1 provlel
of the Contractors License Lew(Chapter 9(commencing with Section 7000)of n 3 0
Business and Professions Code)or that he Is exempt therefrom and the best r eellegetl 3P SHINGLES
exemption,Any violation of Section 7031.5 by any applicant for a permit subjects pplicent to
e civll penalty of not more than five hundred dollars($500).): r] 1 0 HAKES C]1,as owner of the property,or my employees with wages as their sole comp ellen, O ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Busln antl Proles- '
cions Code:The Contractor's License Law does not apply to an owner of propen WOO HINGLES ❑
Improve$thereon,and who does such work himself or through his own employe s, din that
such Improvements are not intended or offered for sale.If,however,the building r rovement
Is sold within one year of completion,the owner-builder will have the burden of pr, PECIFY) - - ❑
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 bulltla or Improves thereon,and who contracts for Such projects
with a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,S&P.C.for this reason
Owner Dere
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: /
❑I have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, Building r
as provided for by Section 3700 of the Labor Code,for the podormance of the work for which this
Perm, le laeueIt G
have end will maintain Worker's Compensation insurance.as required by Section 3700 o1 9 o49�- $eISR11C
tabor Code,for the performance of the work for which this permit is issued,My Workers
Compensation Insurance carrier and Policy number are; Total 0 00
Carrier Policy No PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 100)o �� /A
(Tela faction need not be come of the
If the permit is for one permit
Is i dollars($100)or lase) V V [ ^ CjY1r J(
I certify that In the performance of the work for which this permit le IseuaQ I shell not employ V
any person In any manner so as to become subject to the Workers'Compensation Laws of Call. All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
bare Applicant inspection,I agree to remove all new materials for inspection.
subject to thCE eOWorkerss'Compefnsale n provisionls Of thelcate of Labor Code,Exemption.
mustuforthwithlcecome
comply Applicant understands and willcomply w' I non point
with such provisions or this permit shalgbe deemed revoked source regulations.
I certify that I have read this application and state that the above Information la correct.,agree
to comply with all city and county ordinances and state laws relating to building construction,and All co erin sto be cl "orbefter.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, l/ }
judgments,costs and expenses which may In any way accrue against said CityIn consequence
of the granting of INS permit. SI NATU F 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