R-5669•
•
OFFICE COPY
PERMIT R-5669
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 LAST CALLED INSPECTION,
BUILDING ADDRESS
e4U P_ KJDr tU
/
RESIDENTIAL '/ =:: C OMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
I
YES ❑ If yes — I understand that a Class A
NAMEArt/t:1 e ey
roof assembly is required
NO ❑ Initial I.C.B.O. e
EXISTING ROOF COVERING
1-739 ZeAae Dy-
ADDRESS III)
PHONE z1 q 6 — 317E7
NUMBER OF EXISTING COVERINGS
TO BE REMOVED TO BE RETAINED
CONTRACTOR'S (/, �J 2,016
%
NAME LL) 6,S t e ir �/ IL? CI d— IL
O �IrJ
O
T
ADDRESS cc r--.
TYPE OF ROOF COVERING
CITY a ZIP 2151 'U 12� ST 1�� -
EXISTING
�iD F?' 3)-O y Z
PHONE
BUILT-UP ROOF ❑
LICENSE
NUMBERCo
ASPHALT SHINGLES ❑
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license Is in full force and
effect.
WOOD SHINGLES
License Class C*— Lic. Number
/ ContractorIS)`aa'
Date D= Z- la
OTHER (SPECIFY)
OWNER -BUILDER DECLARATION 0 1PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
Z
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct, Shot, 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 Ne Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he Is exempt therefrom and the basin 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).):
I, as owner of the or my employees with wages as their sole compensation, will do
E] 1,
p
SHAKES P P�
property,
the work, and the structure Is not intended or offered for sale (Sec. 7044, Business and Proles-
O
sions Cotle: The Contractor's License Law does not apply to an owner of property who builds or
WOODSHINGLES
Improves thereon, and who does such work himself or through his own employees, provided that
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ch intended re for sale. however, the or Improvement
w S
Soldwthwonenyear al completion, thot
1.ownetlbuilderr wiill have the burdenofproving that he did
►' tvlttyJ
OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
v
I,as"nor of the properly, am exclusively contractingwith licensed contractors to constructnot
the project (Sec. 7044, Business and Professions Cotle: The Connector's License Law does not
PROVIDE LC.B.O. REPORZWIb. .
to an owner 01property who unlions
and who contracts for SOON projects
with uant t tImprovesIh&eoo,
wltnacontexempt neer pursuant to the Contractor's license Lew.
PROVIDE MFGR. INSTALLATION SPECS.
I am exempt under Sec. ,B 8 P. C. for this reason
Se
Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
Q /_ �- )
2 w
Building 17
I hereby affirm under penalty of perjury one of the following declaration:i
❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of thew for which this
(� uz
permit is issued,
Seismic _70
❑ I have and will maintain Workers Compensation Insurance, as required by Section 3700 of
.
the Labor Code, for the performance of the work for which this permit Is Issued. My Workers
Total 117,70
Compensation Insurance carrier antl Policy number are: r
Carrier SI Ci Policy Policy No. 0373oo]
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N00) o
(This need not completed it the permit is for one hunless.)
fy that I r ceothepermit
certify that In the performance of the work for which this permit is issued, I shell noI employ
is i sued,dollarI shall not
any person In any manner so as to become subj ai to me worker: Compensation Lawn of call.
All roofs shall be inspected prior to any roofing material being
forma.
stalled. If a roof is installed without first obtaining an
Dale —21.— Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It, e`er making th ertlficate of Exemption, you should become
subject to the Workers' Compensation provlslons he Labor Code, you must forthwith comply
Applicant understands and will comply with all non point
PP P Y P
with such provisions or this permit shalQbe tlae red oked,
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
I roof coverings to be class "C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes.
(We) agree to save, Indemnify and keep harmless the City of Cupertino against liabilities,
(—
judgments, costs and expenses which may In any way accrue against said City in consequence
SI NATUREGF-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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY