R 5563 APPLICATION FOR CITY of cuPERTINo
NUMBI RR- 5563
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
a WITHIN F DAYSOFPERMIT ISSUANCE OR
190 DANSSFROM LAST CALLED INSPECTION.
BUILDING ADDRESS
6fL4 0\ Na-?,i V, ,,Oca4
RESIDENTIAL COMMERCIAL OTHER
OWNER'S (��I�- n
HAZARDOUS FIRE AREA
NAME G �"Y� `� �\�CiV YES ❑ II yes understand that a Class A
q � /^1'� rnbly- required.
32� L� { r 4*t •64� N Initial C.B.O.#
I4 i EXISTING ROOF COVERING
ADDRESS�-J,,q� Iy G.(.^'I
PHONE W .� C/'� O `c� NUMBER OF EXISTING COVERINGS
CONTRACTO 'S
NAME 0 L O f am '• \ TO BE REMOVED TO BE RETAINED
ADDREss r TYPE OF ROOF COVERING
CTvszIP 1 ��025
I-E 6 J - 22- 031 EXISTING
• PHONE— BUILT-UP ROOF ❑
LICENSE
NUMBER C` 2�2g Z� ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION C'
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES /
7000)of DiAslon 3 of the Business and Professions Cotle,and my license Is In full force and
effect. ^ p2rq T WOOD SHINGLES ❑ sly
License Class LIc.Number 2S
' �_I(,I- QContractor—( - OTHER(SPECIFY) ` ❑
Date
OWNER-BUILDER DECLARATION PROPOSED
1 hereby affirm that I am exempt from the Contractors License Law I the following reason.
(Sec.7031,5,Business and Professions Coda: 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 ' 1
of the Contractor's License Law(Chapter a(commencing with Section 7000)of Division 3 of the
Business and Profession.Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES /r�` pp II-,�,x t
exemption.An of
ion more
1han fin h031.5 undred any s($5applicant fore permit subject:the applicant to �6,P JV�Q�W
e civil penalty of not more then Ilse hundred yees (h wage: Q�' l/t
❑Les owner sthe ctureproperty,mitt tendedmy or offered for saas le
their sole compensation,sandPrfes. WOOD SHAKES ❑ J
the work,and the structure Is not Intended ores not for yto (Sec.7044,Business hotl build.
s-
alons Codeesth thereon,
,an who
LicenceLewdoesnotapply toanowner ofproperty whoidedt or WOOD SHINGLES j
Improvessoemnts are
who tloensuch r ork himself or eredfrsale.If,
eeownemilding or Improvement ❑
such Improvements are not completion,
leb n,or owner-builder
for seer. ill however,the buntline o i ImprovementIs 3�
not build
ld or I provne e r of for purpose
s the owner-bulltlerwlll 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 Sp.
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO. V
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contraaor(s)licensed pursuant to the Contractor'.License Lew, PROVIDE MFG R.INSTALLATION SPECS.
L]I am exempt under Sec. ,B 6 P.C.for this reason
Owner Date APPLICA ION DAT UATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
J]1 have and will maintain a Certificate of Consent to sell-insure for Workers Compensation, BUII n
as provided suforby Section 3700 of the Labor Coda,for the performance at the work for which this xt���� ¶�
s! IS lsauetl. W ,rUL Sal IT1
have antl will maintain Worker's Compensation Insurance,as required by Section 3700 of
the La r Code,for the performance of the work for which this permit Is Issued.My Workers CITY
Compens on In urence ler enyd�/Pq�III'cy number ere: t� ` CITY Uf• txU!' (Jf, urtHTIN Total
Carrier '�-x Policy No. � 8Q Q� PERMIT AUTHORIZATI N DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If the permit Is for one hundred dollars(5100)or lees.)
1 certify that In the portormance of the work for which this permit Is Issued.I shall not employ
any person In any manner so as to become subject to the Workers'Compensallon Laws of Cell- All roots shall be inspected prior to any roofimaterial being
forniaQ ��rzL,�[ installed. If a roof is installed without fir t obtaining an
Data hs_I " ` Applican inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: II,after making this Certll eta of Exemption,you should become
subject to the Workers'Compensation provision:of the .too,Code,you must forthwith comply
Applicant understands and will comply with all non point
with such provisions or this permit shelQbe deemed rev ked. Source regulations. _
I certify that I have read this appllcation 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 coverin s to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
ep purposes.
(We)
(We)agree to Bede,expense,
and keep harmless the Clry of Cupertino against liabilities,,
--
judgments,coats and expense.which may In any way accrue against said City In consequence
of the emoting BI this Parma, GNATURE OF APPLICANT DATE -
RE-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
h
�® 10300 Torre Avenue
Cupertino, CA 95014
Cupertino Building Division
(408)777-3228
(408) 777-3333 (fax)
Y
March 20, 1998
Homeowner
949 Blazingwood
Cupertino, CA 95014
SUBJECT: REROOF PERMIT
Dear Homeowner:
We have been going through our files in the Building Department, and contacting those
people with re-roof permits remaining "open". Our records show that either you or your
roofing company have not: (1) called to schedule a final inspection, or(2) missed getting
• the sign-off after calling us for a final.
Sometimes an inspector will return to ajob and sign off the permit in the field, but
neglect to inform staff for input into the computer. If this is the situation and your permit
card shows the final sign-off, would you please contact us so we may complete our
computer records? If the permit is not signed off, please call to schedule an inspection for
final closure of the permit.
Because of the large volume of paperwork within the building department, we cannot
separately monitor the progress of each permit. We ask that you give this notification
your immediate attention. If we do not hear from you within fifteen (15) working days,
we will expire the permit and remove the records from our computer.
Thank you for your assistance.
Sincerely,
CITY OF CUPERTINO
Christy Akatiff, Administrative Clerk
Primed on RecVclea P9ner