R 5760 PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5760
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(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
�
1070 1 C) RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes-1 understand that a Class A
NAME roof assembly is required.
NO ❑ Initial I.C.B.O.N
ADDRESS {{ � --' EXISTING ROOF COVERING
PHONE<'4 O LD` ?j 8 ' Z S 3 NUMBER OF EXISTING COVERINGS /
CONTRACTORRP
NAME_ JCJ��✓Y�R /`11 Ciro-
ADDRESS
-y TO BE REMOVED TO BE RETAINED
ADDRESS O fin, / v - TYPE OF ROOF COVERING
anazlP_ 9/Ititcv /�OYYIaL. 4
dn.2t, a. 9 EXISTING
��
PHONE��Al71(�4 — �1 U l D BUILT-UP ROOF ❑ /��
LICENSE /
NUMBER 6 6lo p� ASPHALT SHINGLES ❑ "
E� O
LICENSED CONTRACTORS DECLARATION n
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES Y9
1 7000)of Division 3 of the Business and Professions Code,and my license Is In full torte and
meet. WOOD SHINGLES - ❑
License Cleee� 1.1c.Number � 4 AN$ro
Data y Contmctor OTHER(SPECIFY)
OWNER-BUILDER DECIARA ON PROPOSED
CITY Ur i l I_t��"`�
hereby affirm that I am exempt from the Contractors License Law for the following reason,
(Sec.7031.5,Business antl Professions Cotle: 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 ❑
ofapplicantCo for such permit License Ills a signatl statement that it Ilcensetl pursuant to ins pr 3 of the
of the Contractor'sssion Law(Chapter 9(commencingISexpt with Section 7000)of Division 3 le the
Business and Professions Code)or that he la exempt Infero 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 4�
e civil penalty of not more than five hundred dollaemployees
with
wage: WOOD SHAKES
[:11,as owner ofthe property,t Intended employeeswith wegae aetheir sole cvmpess and colII s- ❑
the work,end the structure le not sLow or offered for cele apply to now owner
of Business and Profen-
improvsthsions eren,The and
Licence Lewd es himself or
his
a property who idebuilds or WOOD SHINGLES
Improves o thereon,entl who does such work himself et .It,how hie own employees,Improvement ed that ❑ (/^
such Improvements are not completion,
or owner-builder
for wL however,the en of pr or Improvement
Is not
ld build or one improve
for purpose
stheowner-bullderwillnevethebumenalprovingthat he tlltl OTHER(SPECIFY) ❑
not bulltl or Improve for purpose of sele.l.
d I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO. UG PUI M
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(a)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
E]I em exempt under Sec. ,B 8 P.C.for this reason
Owner oats
WORKERS COMPENSATION DECLARATION .APPLICATION DATE VALUATION PERMIT FEE
• JJaa
I hereby affirm under penalty of perjury one of the following declaration: Y V r(,`�O
❑I 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 (/
Perm t have
SBlsIT Zo
have entl will maithe pert rmancWorkers Compensation which this
as required by Section Worker's's / r t.(�I/J
C Labor tiotlo,for the performance of the work for which(hie permit Is Issued.My Worker's G
Compensation Inau nee carrier and Polley number ere: Total r an
Carrier � � Policy NAW- PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the permit is for one hundred dollars($100)or less.) - J�� 4
I certify that In the performance of the work for which this permit Is Issued.I shall not am toy O
to
any person In any manner so as to become subject to the Workers'Compensation Laws of Kit- All roofs shall be inspected priorto any roofing material being
fernia' Q�//� �/}/ installed. If a roof is installed without first obtaining an
Date r' y Applicant 0&;67 � . inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,alter making this Cert ale of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workere'Compensation provisions Of the Labor Code,you must forthwith comply pP p y p
with such provisions or this permit shall 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 Oil city and county ordinances and state laws relating to building construction,and All roof coverings obs class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentlonatl property for In-
ap(We) purposes. 4/41/9tf
judgments,agree s save,expenses
and keep harmless the City of Cupertino against liabilities,
of The grist coats and expanses wrath may In any way accrue against ealtl City...consequence
of the granting of this permit. SIGNATURE O APPLICANT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY