R-5459a
a
a
,i PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5459
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.
BUILDINGADDRESS
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RESIDENTIAL -1— COMMERCIAL OTHER-
OWNER'S
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HAZARDOUS FIRE AREA
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YES ❑ loofassemblersoarMthat a Class
NAME I.( ✓IL%}.C. ,�(,
roof assembly's required.
NO Initial I.C.B.O. k
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EXISTING ROOF COVERING
ADDRESS Q`4Z>
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOR'S (– //��
T',(X S4CWT6y�r
TO BE REMOVED TO BE RETAINED
NAME //���� /7^��IIAA �,
/1 %/] /_ /J 7'
ADDRESS 30 &iij 2
TYPE OF ROOF COVERING
/'
CITY & ZIP JO / TI [X i21. YJ%Ll (�C.Y'
EXISTING
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`7 �J
PHONE day / Cl
BUILT-UP ROOF ❑
LICENSE
NUMBER `Y `f'/ 77/
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.
7-7
WOOD SHINGLE ❑
License Class INumber
OTHER (SPECIFY) ❑
Date Contractor
PROPOSED
OWNER -BUILDER 6EZGARATION
I hereby allirm that I am exempt from the Contractors License Lew for the following reason.
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct, alter,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 the Contractor's License Lew (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he Is exempt therefrom and the basis for the alleged
ASPHALT SHINGLES
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dollars ($501
WOOD SHAKES
E] 1, as owner of the property, or my employees with wages as their sole compensation, will do
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Proles-
sionsCode: The Contractor's License Lew 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, 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 contractoge) Ilcansed pursuant to the Contractors License Lew.
PROVIDE MFGR. INSTALLATION SPECS.
I am exempt untler Sec. ,B a P. C. for this reason
Owner Date .
APPLJGAT N DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑ 1 have and will maintain a Certificate of Consent to sell -Insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
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Buildin
Permit Is issued.
-11
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RECn
Seismic
have and will maintain Worker's Compensation Insurance, as required by Section 3700 of 4
^
the Labor Code, for the performance of the work for which this permit Is Issued. My Workers 4
1 r U�.
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Compensation Insurance carrier and-�lpi num¢er ere:
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Total
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Carrier-�.Q1Py1'(�CLn Y7�A;I'i PoucyNo.l,A"�tL2"Qy
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.Q
(This section need not be completed If the permit Is for one hundred dollars ($100) or lass.)
1 certify that in the performance of the work for which this permit is Issued, I shall not employ
All roof:: shall be inspected prior to any roofing material being
any person In any manner so as to become subject to the Workers' Compensation Laws of Call.
fornia.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
°t CEof
Ethe Workers' sionls
Applicant understands and will comply with all non point
Compensation prroviafter
oftheicate
sub Labor Code, yoion u must forthwith comply
with such provisions or this permit shalfbe deemed revoked. y comply
source re ulations.
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 Of vering CI ss"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,
OJn_
•/
judgments, costs and expanses which may in any way accrue against said City In consequence
G TURF OF 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY