R 5189 PERMIT R_ 5189
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS
180 DAYS FROM LAST CALLED INSPECTION.
Q
MA &IekmHN �/, /i e RESIDENTIAL COMMERCIAL OTHER
OWNER'S, I n ' '" . HAZARDOUS FIRE AREA
M Q AAI & /1 � YES ❑ It yeas I assembly
is req that a Class A
NAME _ wIYA� ll./N1/eee]]]XXC//N1��WWW H Itys-Iude istandthat
NO,4 Initial I.C.B.O.#
ADDRESS EXISTING ROOF COVERING
PHONE YJ�+D ZZ�"' MBER OF EXISTING COVERINGS I
CONTRACTOR' TO
C�D.�s t�c�fin� Co TO BE REMOVED I TO BE RETAINED
NAME
ADDRESS K n6 EASt�, 11 4I' TYPE OF ROOF COVERING
clry s zIP c�J 7 �[f-/� 7 I7 ((/ '146"
EXISTING
PHONE_416 ? Z� Z Z.5 ?4
BUILT-UP ROOF
LICENSE
NUMBER 915 ASPHALT SHINGLES ❑ -
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,entl my license Is In full force antl
effbct. - (�/2/(� WOOD SHINGLES ❑
License Class C 39 Llc,Number "7 1LJ /5
Det. 9P Contractor e �N� OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION VPROPOSED
I hereby affirm that I am exempt from the Contractors License Lew for the following reason.
(Sec.70315.Business and Professions rep Coda: Any city or Bounty which requires e permit to
construct,for er,such
Improve,demto file signed statement
air eny mentrthat e,prior toile)ssuance.pursuant also theprovirequires the BUILT-UP ROOF ❑
of Ono
for such permit to Ills a elgnstl statement Incl he Is licensed pursuant m the provisions
of the ss an Pro License Lew(Chapter h(commencing with omSectionand 7000)of for the 3 of 119
. exam ptio and violation of Code)or that he Is exempt therefrom end the heels for the alleged ASPHALT SHINGLES ❑
exemption.Any violationofhan Section five hundred
by any applicant for a permit subjects the applicant to
e civil penalty of not more than five huntlrad yeesre with
wage WOOD SHAKES
❑I,as owner of the property,or to ded employees with wagee as their Bale compensation,will do s.
the work,and the structure Is not intended or offered for sale(Sac.7044,Business and Proles-
sionsCode:The Contractors License Law does not apply to an Owner of property who builds Or WOOD SHINGLES ❑
Improves thereon,end who does such work himself or through his awn employees,provided that
such Improvements are not Intended or offered for safe.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 safe.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew 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.
O 1 am exempt under Sec. ,B 6 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury ono of the fallowing declaration: 0.
❑1 have and will maintain a Certificate of Consent to sell-insure for Workers Compensation, A ^� Building
TU
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this p�� b,Z2_5 g
permit Is Issued. Hlf�r SeIsmIC
❑ have and will tel Performance
Worker's Compensation the work
Insurance,as rm it Is I by Section Worker's
's JA Q 8 na
the Labor Code,for the pedormance of the work for which this permit le Issued.My Worker's
Compensation Insurance terrier and Policy number ere: Total
ILL
Carrier Policy No. E MITAUTHORIZATION DATE
CERTIFICATE OF 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 shell not empjoy -
any person In any manner so as to become Oct to the Workare'C iatlon Laws of Cell- All roots shall be inspected prior to any roofing material being
forma' 7pr installed. if a roof Is installed without first obtaining an
Date I� ✓- 9 Appllce yAlul inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after makln a Certificate of Exemption,you should become Applicant understands and will
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP comply p y with all non point
with such provisions or this permit shelube deemed revoked, sOUfCe 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 A of coverings to be class' , better.
hereby authorize represontatives of this city to anter upon the above-mentioned property for In-
spection purposes. �n axah � 1 1-071?-9,P� /y /�
(WO)agree s save,pe Indemnity w and keep harmless the City of Cupertino against liabilities, 1 u/ A.lti ,7t s/)h/yKi 1? Cy/,P
lutlgmente,coats entl expenses which may In any way accrue against eeltl Clty Inconsequence
of the granting of this permit. TORE 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 i