R 5897 PERMIT R_ 589
7
• 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.
qWPBULDING
A�DDREESSS �Z _ RESIDENTIAL /
COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA
,cQ VES �j Ilyes—I understand that a Class A
NAME i_y1 r/�•'� tel. `� `�� root assembly is required.
p p NO C] Ingial I.C.B.O.If
ADDRESS !1�-3� �r AJ �` t EXISTING ROOF COVERING
PHONE C T'�8 -2- ��_ OD17 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S �p '
NAME 4�(f°a�t/� (..�17'V �'`� TO BE REMOVED 9a ocPC (*,l BE RETAINED 'T
ADDRESS /+ TYPE OF ROOF COVERING
CITY aZIP &4evei SING
XI T
PHONE � L � j" IRV,) BUILT-UP ROOF / ❑
CENSE
NIUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em Business
under Professions
of Chapter 9(commencing with Section WOOD SHAKES F
7000)of Division 3 of the Business and Profaselone Cade,and my license Is In full lone and
effect,
�� .� WOOD SHINGLES ��'❑
License Class Lic.Number /
Data Contractor
OTHER(SPECIFY)
OWNER-BUILDER DEC TION PROPOSED
I hereby anlrm that I am exempt from the Contractor's 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 Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Coda)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($500).): 0 fy
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profen
cions 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 omployees,provided that
such Improvements are not Intended or offered for sale.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 FrfSPECIFY I�f
not build or Improve for purpose of sale.). OTTHY ) NJ
I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec,7044,Business and Professions Code:The Contractor's License Law does not 8�
PROVIDE 1.1.0.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Lew. �p�l9oSMIDIROGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason t17,�t 1
J
Owner Date
WORKER'S COMPENSATION DECLARATION , PQLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: / O�
❑I have and w111 maintain a Certificate of Consent to self-insu o for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Coda,for the performance of the work for which this /
permit is issued, //�—I/ k'�// SeIsmID 5 0
❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 of l.i" 1 (� Q I]l
.the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's LLLYYYY"' R
Compensation Insurance carrier and Policy number are: Total / `v f o
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.QD ��
(This section need not be completed if the permit Is for one hundred dollars($100)or fess.) /1
I certify that in the performance of the work for sibich this permit Is Issued,I shall not employ N
any person in any manner so as to become subject to the Workers'Compensation Laws of call- All roofs shall be inspected prior to any rooting material being
fornla.
installed. If a roof is installed without first obtaining an I
Date Applicant inspection,I agree to remove all new materials for inspection.
NOT subject 1oETO APPLICANT:the Workers'Compensation provisions of theicate LaborCode,you mustuforthwithlbcomGly Applicant understands and will comply with all non point
with such provisions or this permit shal@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 coverings to be class ,Y or better.
hereby authorize representatives of this city to enter upon the alkwo-mentioned property for In-
spectionpurposes.
(We) C
(We)agree to save,Indemnity and keep y I harmless me Clry of Cupertino Ci y...against liabilities, /
judgments,caste and expenses which may In any way accrue against said Clry Inconsequence SI U APPLICANT DATE
of the granting of this permit.
is PRE-INSPECTION: PLYWOOD: IN-PRQGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. 1 DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF-SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY