R-5478 PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMB R R- 547
8
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 77-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
8 L RESIDENTIAL_ COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
'L A ( �O t. 1 YES If yes–I understand that a Class A
NAME V K V roof assembly Is required.
NO 1W Initial I.C.B.O.a
ADDRESS 5� � S• �� ✓ �! EXISTING ROOF COVERING
PHONE - `-4 0 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S 'n �/� �� / 1,� `/
NAME S jld N A' TV IQrc, t t)o F ]yyC TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY&zip IPJQ .PAIZA %--(oWA * ✓ SV J(4DO EXISTING
PHONE (SOP) 4(-77Q— I D BUILT-UP ROOF ❑
CENSE
NUMBERdftdiO� (p ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am Ilcensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑ l�/
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
WOOD SHINGLES ❑ q
License Class GG pp Lid.Number GAGO
/y� L_ /
Data t.b`Z."l�L � contmctor����• t �I OTHER (SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
1 hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Prof9sslons Code: Any city or county which requires a permit to c7T
construct,alter,Improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOFapplicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of theContractor's License Law(Chapter 9(commencing with Section 7000)of Division3of theBusiness antl Professions Cotle)or that he is exempt therefrom antl the basis for the alleged ASPHALT SHINGLEexemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant tp a civil penalty of not more than five hundred dollars($500).): WOOD$HAKES❑1,as owner of the property,or my employees with wages as their sole compensation,will do the work,antl the structure Is not Intended or offered for sale(Sec.7044,Business antl Profes-
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,em 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 bu lids or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
p 1 am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
711 have and will maintain a Certificate of Consent to self-Insure for Worker'9 Compensation, {�(�/: /. S l� U , Do
Building/
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this t/111 `� ✓( J
permit is Issued. ) Seism
the
^
❑1 have and will therein Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's /D-7-46-0.7,�o
Compensation Insuranq�cerrler a�4Policy number ere: Total
Carrier ST T�i <n1 N� policy
No.S)I -f1 ,-1_010 3 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.D -�` ^�
(This section need not be completed It the permit is for one hundred dollars($100)or less.) 1 l O � A 0 s�Q
I certify that in the performance of the work for which this permit Is Issued,I shall not employ v I
any person In any manner so as to become subject to the Workers'Compensation Laws of Ca11- All roofs shall be inspected prior to any roofing material being
forms. p installed. If a roof is installed without first obtaining an
Date (.D'-2T_,q Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,alter making this Certificate of Ex. pl ou should ecome Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Cade,you mus comply PP P Y
with such provisions or 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 All roof verings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes. �p
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, J11, UU
judgments,costs and expenses which may In any way accrue against said City In consequence SIGNATURE OF APPLI T DA E
• 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY