R-5485 ' PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 5485
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 /�' /✓�
A `� O ZZ r-'/'�� R Y✓ R - RESIDENTIAL_" COMMERCIAL OTHER
OWNER'S r o fir' HAZARDOUS FIRE AREA
NAME�e- A �l�.t /✓t E�l �N� YES ❑ If istandthat ed Class
roof assembly Is required.
/ NO ❑ - Initial I.C.B.O.E
ADDRESS ` OO2- 2'o�/B Y99 NE • EXISTING ROOF COVERING
PHONE Zf2, •O-/ 7 / NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME Cf]/�-N ��W61Q�- w`�l IWMI TOBEREMOVED TO BE RETAINED
ADDRESS902If W L'E P, �4V`e 61140y rA. 9jv TYPE OF ROOF COVERING
CITU 8 21P
EXISTING
PHONE
PHONE (0%/ " _3��� BUILT-UP ROOF ❑
LICENSE 30 El ASPHALT SHINGLES ElNUMBER
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
License Class C— � Lic.Number 6 30 WOOD SHINGLES ❑
OTH F!FJData//' ContractorOWNER-BUILDER DEC ATION R PO EDI hereby affirm that I am exempt from the Contractor's License Law for the following reason. NO 1/(Sac.7031.5,Business and Professions Code: Any city or county which requires a permit to Y
construct,alter,improve,demolish,or repair any structure,prior to Its issuance,also requires the
MZ- PROOF
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions Yc
of the Contractor's License Law(Chapter g(commencing with Section 7000)of Division 3 of the d
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASP
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).):
❑I,as owner of the property,or my employees with wages as their sola compensation,will do WOOD SHAKES
the work,and the structure Is not Intended ores not for sale n(Sec.wner Of,Business and uilds or
alone Code:The,anwho d License Law tlimelftapplytoanowner Of Property whobuildsWOOD SHINGLES ❑
Improves thereon,entl who does such work himself or through his own employees,provided that
suchimprovementswithin one year
are not completion,
leb n,the
owner for sale. ill however,the buildingr or Improvement
not bull or
prove for purpose
sale.).
the owner-bulltler will neve the burden or proving that he Oltl OTHER (SPECIFY)
not build as
Improve for purpose of se clu `/
❑I,ec owner of the property,am exclusively contracting with Contractors
tracto rcontractors to construct
the project(Sac. of pr Business and Professions Code:The and who co9License Lewdoes not PROVIDE LC.B.O. REP
apply to c contractor(s)
properly who pursuant
or Improves thereon,and who contracts for such projects
calm a contexem t licensee pursuant to the Contractor's License Lew. PROVIDE Ml INSTALLA II SPECS.
❑I em exempt antler Sec. ,B 8 P.C.for this reason Xx
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: �� CO
I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this / , /�T,s
permit is Issued. p/_ y) 001-3 Seismic .�( e
lyrbeve and will the performance
rmancWorkers f the rk for Insurance,as required by Section Worker's's /1/ / AT
the Labor Code,for ins performance of the work for which this permit Is issued.My Worker's
CompenseCtlo�Insurance carrier entl lfllcy number are: (*S-7 (� Tota
Carrier AAI �Uvd p011cyNO./27 /3-/ 7 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.] '31
T /(This section need not be completed it the permit Is for one hundred dollars($100)or less.) �.�\ V 1 �
I certify that In the performance of the work for which this permit Is Issued,1 shall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell- All roofs s a I be inspected prior to any roofing material being
lornla' / installed. If a roof is installed without first obtaining an
Date ll-'3—?7 Applicant �'�� 0 k-4 inspection,I agree to remove all new materials for inspection.
subN�toEheOWorrkerss'Compensation proviANT: It,after sions oftheCertificate
of
Exemption
de you mustuforthwllitthbecome
comply Applicant understands and will comply with all non point
with such provisions or this permit shaif;be deemed revoked. source regulations.
I certify that I have road 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 b ass"C"or better.
hereby authorize representatives of this city to anter upon the above-mentioned property for in. / ^ ^
spection purposes. 1_3 Y
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, /
judgments,costs and expenses which may In any way accrue against said City in consequence SI RE 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