R-5684 PERMIT
APPLICATION FOR CITY of CUPERTINO NUMBER R_ 5684
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (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 \/��/
D{" RESIDENTIAL / COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
( Gl I YES ❑ If yes—I understand that a Class A
NAME Frea �,M -L \ I� �I�,—. NO roof assembly Is required. LC.B.O.#
ADDRESS QQO� I C'_A bJn1£ -F t EXISTING ROOF COVERING
PHONE S NUMBER OF EXISTING COVERINGS TLcJ
CONTRACTO�R'Sf�' '�}-�('�� �t {� M10
NAME z•x�— R1 rI1 /\ LJ o �✓��7 TO BE REMOVED TO BE RETAINED
ADDRESS �j-��/!/�-�/ / /�I—� , �c T'[/ TYPE OF ROOF COVERING
clTvazlP �`�`� 7 ✓C �1/LU/ JAL EXISTING
PHONE -�z5-93 BUILT-UP ROOF ❑
CENSE
NUMBER 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' WOOD SHINGLES
License Class Liu Number
Date Contra Contractor OTHER (SPECIFY)It �� ❑
OWNER-BU
theConRDECLLicensN PROPOSED
hereby affirm Bu that em exempt from the e: Any city License Lew for the fallowing permit
to
(Sec.70315,Business and Professions Code: Any city or county which requires requires permit to
applicnconstruct,alter, hpermittfile asigned air staeny mentrthatre,Is licenseor to Issuance,els oproviins BUILT-UP ROOF
applicant for such permit a Ills a signed statement that la licensed pursuant to the provisions
of the Contractor's License Lew(Chapter 9'commencingisex pt with therefrom
and the b of Division 301 the
• Business and violation Of Sectio Or that he le exempt therefrom entl the bails for the applicant
to ASPHALT SHINGLES
exemption.Any violation of hSection 7031.5 by any applicant for a permit subjects the epPlleant to
e civil penalty a not more then live hundred dollars(h wag): WOOD SHAKES
1,as ownerofthe property,t I to ded employees with wages as their sola compensation,wolf s- ❑
the work,and he structure Is not Intended or offered for sale(sea owner
of property
and builds
or
Code: The Contractor's License Lew tome not apply to an owner of property who bullet or WOOD SHINGLES
Improves thereon,and who does such work offered
himself or through els own employees,improvement provided that ❑
such Improvements aro not completion,
leb n,or o#wnetl for sale.I(however,the building of improvement
Is sold ntbuild or
prove for purpose
sale.).owner-builder will have the burden of provingthat hedid OTHER(SPECIFY) ❑
not built or Improve for purpose of wale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(See.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 contractor(s)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B$P.C.for this reason
Owner Date - APPLI TION 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 self-insure for Worker's Compensation, / O�� 0 �..5 ^ OQ BuildingMow:—
as
provided for by Section 3700 o1 the Labor Code,for the Performance of the work for which thio H •Jl
permit is Issued. C Seismic _l
L have and will the pelf Worker's Compensation the work
Insurance,as reitis i by Section Worker's
's U
the Labor Cone,for the performance of Policy
work lar which this permit Is Issued,My Worker's F C' P / Total
Compensation Insurance terrier and Policy/n�umber are: ���� /yf�/}
Carrier IF 00 Policy No.gas PER FUAUTHO RATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need not be completed It the permit is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit Is Issued,I shell not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Call- All roof$ II be i ected for to any DD ng mater I ng
fornia. installed. If a ro f is installed without/first obt nin an
Date Applicant inspection,I agree to remove all new ma rials for it spection.
subj
ect too the s'Compensation APPLICANT: provisionls of the1cate of Laborr Coda,Exemption,
musttf0 thwlithbecome
Comply Applicant understands and will comply with all non point
with such provisions or this permit shall 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 co e ' gs to be Ss or b tt r.
hereby authorize representatives of this city to enter upon the above-mendonetl property for im
spection purposes. ��
(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 GNA RE PPLI ANT 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