R-5547 APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R— 5547
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN ISO DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS///�
RESIDENTIAL.�L_COMMERCIAL OTHER
OWNER'S 1 M ( I ,,� / HAZARDOUS FIRE AREA
NAME/ xi�h:• •/ •r?,yd �7' IST C;_/A VES ❑ reof assembly is requirend that d. Class A
( - NO Inl6al I.C.B.O.N
ADDRESS 101C) L—A-2.,];t- St. S.aMAtp 9 4�-1 Z�, EXISTING ROOF COVERING
PHONE LI dB Z9 3 NUMBER OF EXISTING COVERINGS
CONTRA
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS / TYPE OF ROOF COVERING
- 5...—
CITY SZIP '14353 So. � ^SE MSn 45//7
' EXISTING
�• PHONE! - q�I75-01n BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION •
1 hereby adlrm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is in full force end
effect. WOOD SHINGLES ❑
License Class 3 Lic.Number
OTHER(SPECIFY) ❑
Date C° actor
OWNER- ILD_ El ,c RArn PROPOSED
hereby affirm that em exempt from M..c.rrl� r'e Llcans Law for Iha bllowinq reason.
(Sec.7031.5,Business and Professions Cotle: An city or c v which the
a permit to AUGconstruct,alter,Improve,demolish,or repair any stru or to its issuance,also requires the BUILT-UP ROOF U /al•.�
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions fry.pyp
01 the Contractor's License Law(Chapter g(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 SHINGLE$TY OF cUP
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to N
a civil penalty of not more than five hundred dollars($5001.): WOOD SHAKES ElNO
❑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 for sale(Sec.7044,Business and Prolas-
elonsCotle: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 employees,provitletl that ,7
such Improvements are not Intended or offered for sale.I(however,the en of pr orimprovement
Is sold not
or
move°rofcoposetof sale.).
E]
have the burden of proving that he tlltl OTHER(SPECIFY)
not b 1,as
Improve for purpose of sal°.).
I,ec owner of the property,am exclusively contracting with Incensed contractors LicseI-to construct
the protect(Sec.7044,Business andProfessionsor improv Code:The Contractor's License Lawdoes not PROVIDE LC.B.O.REPORT NO.
apply to contractors)
owner of properly who builds or Improvesthereon,and who contracts for such projects
with am
under
Se pursuant t°the Contractors License Lew. PROVIDE MFG,R.INSTALLATION SPECS.
I ❑I am exempt under Sea ,B 8 P.C.for this reason
4 Owner Date APPLICATION 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 sell-Insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this rx�
permit Is Issued. y,.� C� $eISmIC
ave and will maintain Worker's Compensation Insurance,as required by Section 3700 o1 V/7// 3341 3,
the La Code,for the performance of the work for which this permit Is Issued.My Worker's Total
Compensation I�nssuurance Carrier a[ntl�Policy1rWmber are: L
Carrier �T 4�e- w"�c+ Policy No. c—/�—w PERMIT AUTHORIZATION D
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(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 1 arini Is Issued,I shall not employ
any person i any manner s0 ae to became 0 a or r Clnpensallon Laws f call. All roofs shall be inspected prior to any roofing material being
prole. installed. If a roof is installed without first obtaining an
Date Ap went inspection,I agree to remove all new materials for inspection.
NOT E APPLICANT: If,eft me ertiilce of Exa pilon,you should become Applicant understands and will comply with all non point
subject °the orkera'Compensetlon provisl sol the or Code,you must forthwith comply PP P Y
with such provisions or this permit shalgbe d med rev ad. source regulations.
I certify that l have read this application an at the above Information is correct.l agree
to comply with all city and county ordinances and state laws relating to building conatructlon,entl roof covenn -Cp be ,lass"C" rbetta r.
hereby authorize representatives of this city to enter upon the above-mentlanatl property for In- / 1
spectlon purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against Ilabillbes 4
judgments,costa and expenses which may 10 any way accrue against sold City In consequent; TURF APPLICANT DATE
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: I -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