R-5480 e.. - PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5480
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 /+ �li Ave .
C -
CG.gsa/
Jj � 1 RESIDENTIAL__COMMEflCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAMEroof assembly is requiretl.
NO Initial I.C.B.O.k
� .� Ate EXISTING ROOF COVERING
ADDRESS h.� ..-�^T„ry ��/'LQ. a" riz
PHONE d — O O NUMBER OF EXISTING COVERINGS
CONTRACTOR'S'/
✓Q,I)(1✓S {,_u4'_
C�n_re,�pp / TO BE REMOVED TO BE RETAINED
NAME
ADDRESS r I- � �A (" r EXISTING SPE OF ROOF COVERING
CITY 8 zip—/ Q /Cum
PHONE (4d? Y.s 3 — (39- BUILT-UP ROOF ❑
LICENSE NUMBER /S3�'6 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 lull force and
effect.
WOOD SHINGLES ElR
License Class ✓ Lic.Number 66�9 CPO/
Date //�3-�] ContractorDL2OTHER (SPECIFY) ❑
OWNER-BUILDER DECLARATION R ED
I hereby affirm that I am exempt from the Contractors License taw for the hollowing 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 UILT- ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 9(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 "ASOHALT SHINGLES p Elexemption.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).): WOO[ HAKES
E]1.as owner of the property.or my employees with wages as their sole compensation,will do O�
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes. y
sions Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLE*' �(
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or allered for sale.It,however,the lou llding or Improvement
sscIdwithin one year ofcompletion,the owner-bullderwill have the burden of proving that he did OTHER(SPECIFY) `urrh
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct GNU 'Ce
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO. p.
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 Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. .B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
ZI reby affirm under penalty of perjury one of the following declaration:
I nave and will maintain a Certificate of Consent to self-Insure for Workers Compensation, Building
e provitled for by Section 3700 0l the Labor Code.for the performance of the work for which this
permit Is Issued. Seismic
-11 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the tabor Code,for the performance of the work for which this permit is issued.My Worker's �f
Compensation Insurance carrier and Policy number are — �..yy-- 3 `ayr�,� Total
Carrier �7(ZlO �S x'9115- yNO./YKru2-3638-nD PERMIT AUTHORIZATION Dr
E/
F EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If 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,Ishall not employ
any person In any manner so as to became subject to the Workers'Compensation Laws of Cali- All roofs shalfbe-Inspected prior to arty r offing material being
lamla. installed. If a roof is installed withOL It first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE a APPLICANT: e,after making this Certificate of oExemption,,youmust forthwith lccomply Applicant understands and will comply with all non point
subject to the Workers'Compenaater ki fig this C the Labor Code,
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 coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes,
�'� �/3-9
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,coats and expenses which may In any way accrue against said City in consequence
of the granting of this permit. SIG ATURE OF APPL C NT DATE
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