R-5665 PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMBER R— 5665
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
l1; �40QA�LL� RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
k/�n r ,� f. 7 , 1�' ) YES ❑ If yes—I rnblerslanq that a Class A
NAME t " --D 1 ��-•�/ root assembly is requiretl.
NO ❑ Initial I.C.B.O.q
ADDRESS C_
� EXISTING ROOF COVERING
PHONE l I `(✓ l NU O EXISTING COVERINGS
CONTRACTOR'S '
r`1 C ��J.+./ .� (yr TO BE REMOV _TO BE RETAINED
NAME--c— 175 r y k 1 ,{W��t ��t/�,
i�t V^"'`J • ""v TYPE OF ROOF COVERING
I(
ADDRESS "� �'rlr ._ x 'I
CITV&ZIP c���TL�y EXISTING
PHONE 1 l s-� L+ 1� - ���-� BUILT-UP ROOF ❑
LICENSE
NUMBER H ASPHALT SHIN WICEIVED
LICENSED CONTRACTORS DECLARATION
thereby affirm that I am Ilcensed under Provisions of Chapter 9(commencing with Section WOOD SHAKE SEP i ( 97
7000)of Division 3 of the Business and Professions Code,and my license is in full force and -
eHect. 1-1 FS WOOD SHING S
License Class'' OTHER(SPECT
Lic.Number Y: ❑
Dale .1 ZZContractor
ANI
R-BUII DECLARATION
I hereby a81rm that I am exempt from the Contractor's License Law for the following reason. PROPOSED
(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 ❑
applicant for such permit to fila 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 Pot esslans 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 y�
a civil penalty of not more than five hundred dollars(S500).): WOOD SHAKES ElI,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 Profes.
dons Coda:The Contractor's License Law does not apply to an owner of property who Wild.or WOOD SHINGLES E]mproves thereon,and who does such work himself or through his own employees,provided that
such improvements are not Intended or offered for sale.It,however,the building or improvement
Is sold within one year of completion,the owner-builtler 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(Sac.7044,Business and Professions Cotle: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 carnations)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
C]I am exempt under Sec. ,B 8 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 sell-insure for Worker's Compensation, Building
57
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this n Q ,�
permit is have
an. 7-f7 •� fAo /
❑ have and will maintain Worker's Compensation Insurance,as required by Section 3700 of l ( V N— SBISmIC
the Labor Code,for the performance of therk for which this permit is issued.My Worker's Total
Comp�\¢tio1�n In, nce ce rend re:Policy n ber aC
Carrie „]�,` PolicyPERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE S1 00)
o
(This section need not be completed ii the permit is for one hundred dollars($100)or less.) Z
I certify that in the Performance of the work for which this permit is Issued,I shall not employ
any person In any manner so as to become subject to the workers'Compensation Laws of Call. All roofs shall be inspected prior to any roofing material being
foram p �'���� installed. If a roof is installed without first obtaining an
Date.l L !— C Applicant nspection,I agree to remove all new materials for inspection.
NOT I E TO APPLICANT: IL after making this Certificate of Exemption,you sh Id bete Applicant understands and WIII comply with all non point
subject to the workers'Compensation previsions of the Labor Code,you must forthwith camel pP P Y P
with such provisions or this permit strophe 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-mentloned property for In.
spection purposes. ` -
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
• ludgmenis,costa and expenses which may in any way accrue against said City in consequence SIGNATURE F PLICANT TE
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 ROOFS HALL BE PROVIDED FOR INSPECTION
OFFICE COPY