R-5350 PERMIT R' 5350
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
C/o/ �J) ,,,f
rZ€Ln wood RESIDENTIAL_,COMMERCIAL OTHER
OWNER'S + HAZARDOUS FIRE AREA
m�2f�n INtrlsap YES ❑ It yes—IunderstandthataClassA
NAME roof assembly is required.
NO _ Initial I.C.B.O.N
ADDRESS 90 ! 73C.A7_E�n!J Wood EXISTING ROOF COVERING
PHONE 414& — 6Y 33 NUMBER OF EXISTING COVERINGS L
CONTRACTOR'S
(l.NAME-0U&M,5 2004tH G TO BE REMOVED TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITYSZIP Io3i ( L�5 DnOn3 w �r�ta�r.;� SSD/y
r EXISTING
PHONE 2n— S(2 BUILT-UP ROOF ❑
LICENSE
NUMBER 7 L47y 09 ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commencing r action WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In full 1 and
enact. WOOD SHINGLES El
License Clas C 39 Lic.Number Vim/
Data /`� Contractor OTHER(SPECIFY) El
OWNER-BUILDER DEC RATION ED
I hereby affirm that I am exempt from the Contractors License Law for the following r
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit o
construct,alter,Improve.demolish,or repair any structure,prior to Its issuance,also nodules th BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he is licensed pursuant to the provision
of the Contractor's 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 basis 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(8500).): WOOD SHAKES P A Y D❑
D I,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 Or sale(Sec.7044,Business and Profes-
sions Coda:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLE`�PR a 4
Improves thereon,and who does such work himself or through his own employees,provided that
such improvements are not Intended or offered for said.It,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(SPEW, ❑
not build or improve for purpose of sale.). UI VUY
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct LH f INU
the project(Sec.7044,Business end Professions Code:The Contractor's License Law does not PROVIDE LC.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 rho Corrector's License Law. PROVIDE MFGR.INSTALLATION SPECS.
D I am exempt under Sec. ,a 8 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: R `.
❑1 have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, BUIIdin lbr
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.an $BISf111C 4l
❑I have and will the performance
rmancWorker's f the work
for Insurance,as required by Section 3700's [/ /q 7 \
the Labor Coda,for the pedormance of the work for which this permit is issued.My Worker's 7 1/ Total
p Compensation Insurance carrier and Policy number are:
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.D 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 shall not employ
any person in any manner so as to became subject to the workers'compensation Laws of can- All roofs Shall be inspected prior to any roofing material being
fornia. C installed. If a roof is installed without first obtaining an
Dare y r q T 7 Applicant � `�— inspection,I agree to remove all new materials for inspection.
NOT1c TO PPLICANT: 11,after making this Certificate of Exemption,you should become Applicant understands and will om I with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP P Y P
with such provisions or this permit shall be deemed revoked, Source regulations.
I certify that 1 have read this application and state that the above information Is correct agree
to comply with all city and county ordinances and stela laws relating to building construction,and All roof coverings tQ be C Ss` Iter.
herebhereby authorize representatives of this city to enter upon the above-mentioned Property for In. ^ p �-r �//y���
y npurposes. \ �/x�(�
(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 SIGNATURE 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY