R-5269 PERMIT R_ 5269
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
• 160 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/,A25 D2 v
r RESIDENTIAL COMMERCIAL OTHER
OWNER'S p /, �vJ HAZARDOUS FIRE AREA
v Lf� ��'�/�N�ZD YES ❑ If yes—I understand that a ClawA
NAME roof assembly is required.
NO Initial I.C.B.O.p
ADDRESS Z_,VZr �� G �'�'� EXISTING ROOF COVERING
PHONE x7'15-7 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
'^ r TO BE REMOVED TO BE RETAINED
1 NAME �f c-G L1l
ADDRESS
CITY B ZIP '� GO /� � PE V IN
EXISTING
PHONEY � BUILT-UP ROOF ❑�/
LICENSE N—TC� ^ / ASPHALT SHINGLES ❑�. e
NUMBER J 3 co
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of�9 Business and Professions Code,and my license is In full force and C�
effect. 3 q WOOD SHINGLES P A
License Class Lie.Number 7 y
_ - OTHER(SPECIFY) `C�� ❑
Deis �P Lf Contractor �y
OWNER-BUILDER DECLA ATI PROPOSED {;/n. 2 kroV
I hereby affirm that I am exempt from the Contractor's Lice Law 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 Q-1 LUh���n
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions 4 V
of the Contractor's License Law(Chapter 0(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 SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to ^
e civil penalty of net more than five hundred dollars(h wage: ( WOOD SHAKES r( � �
❑Irks and
er the of thestructure
I not I my tended or offered wages as(Sec.their sole compensation,sanddrill do ❑ v
the work,end the structure la not Intended or offered for sale Sec.7044,Business and Profes-
Isions mproCode:The Contractor's License Law does np or through his
nn employers.wrovidedsor yy00D SHINGLES ❑ / +����p
Improves thereon,and who's Li such nse work himselft athroughhieown employees.wo builds
dthat
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 OTHER(SPECIFY)
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project face.7044,Business and Professions Cade:The Contractors 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 connections)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
]1 am exempt under Sec. - ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
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 Code,for the performance of the work for which this
permit have ed, s p/ �y ,•%/� /�/� , ,S`elsm,c
❑ have and will m In Workers Compensation Insurance,as squiredsu d.My
370001 ��?ll (7 vJ
the Labor Cotle,f e edormanee of the work for which this permit Is Issued.My Workers
e Compensatlon In u ca liar and mbe/e: ^� Total
Carrier �,LL Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE EN EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.E]
(This section need not be completed It the permit Is for one hundred dollars($100)or lass.)
I certify that In the performance of the work for In Permit Is Issuad I shall of ploy
any person In any manner so as to become au Hot a A.&CO f call- All roofs shall be inspected prior to any roofing material being
fornix. installed. If a roof is installed without first obtaining an
Data APPliceni inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,alter making this fiesta of Exemption,you should become Applicant understands and will comply with all non point
subject t0 the Workers'Compensation provision he Labor Code,you must forthwith comply PP p Y
with such provisions or this permit shalr;be dee tl revoked. OUfCe 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"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes. — 1
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may in any way accrue against said City In consequence• L DATE of the granting of this permit
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP.A�zzzzzzzDAT 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