R 5993 PERMITR" 15993
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS
100 DAYS FROM LAST CALLED INSPECTION.
/1
-r L)r3A C'c'. RESIDENTIAL COMMERCIAL OTHER
OWNER'S /F 1, r HAZARDOUS FIRE AREA -
NAME tt Le� l Z MOM K A/VAriA VES E] It yes-I understand that a Class A ,
roof assembly is required.
/1,�, NO ❑ Initial I.C.B.O.W
ADDRESS-11-14:1, �rA LIrJA ['�'. - EXISTING ROOF COVERING
NJ,J
PHONE ' NUMBER OF EXISTING COVERINGS
CONTRACTOR'S - 0-✓ -
TO BE REMOVED I TO BE RETAINED
NAME
D., N
ADDRESS Q ` 'r TYPE OF ROOF COVERING
CITY&zIPZZ�?t?_ �^Ltar L,0 AVF , 41. , q51 1a,
PHONE U��b l IS BUILT-UP ROOF �.
❑ 2p1
LICENSE
NUMBER 554 g561 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby adlrm that I em licensed under provisions of Chapter B(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 ❑
License Class C� Llc.Number
Data � Contractor AI5,CAtXA ' D x OTHER (SPECIFY) PJ I
OWNER-BUILDER DECLARATION PROPOSED JULO Pa
I hereby affirm that I am exempt from the Contractors License Law for the following reason. 'JV O p p�mrD
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to Y17
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuancealso requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pusuani to the provlelons CITY of the Contractor's License Law(Chapter g(commencing with Section 7000)of Division 3 of the Ut UL'i-cn I IlV(}
Business and Professions Cotle)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES /g"`
exemption.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).):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profile.
sions Code: 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,provided that
such improvements are not Intended or offered for sale.If,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 exclusive contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew 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 contractors)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
[II am exempt under Sec. ,B&P.C.for this reason
Owner oats
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
-
I hereby aHlrm under penalty of perjury one of the following declaration: /
[II have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building O
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this �p1
P"M"
h Issued, ✓ (b� `J I l�� Seismic
L have and will maithe performance
Worker's Compensation the workfor which ce,this as rmit red by d.My
370001 �`� UUU VVV
1, 20
JAL bor Code,for the penormence of the work for which Ihla permit la Issued.My Worker's / �
Compensation Insurance carrier and Policy number are: Total
J.
Carrier _x � rt,'Uh Policy No. �+'✓ Iia' PERMIT UTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.[] wl
(This section need not be completed If the permit is for one hundred dollars($100)or fese.)
I certify that In the performance of the work for hlch thle permit Is Issued,I shell not employ
any person in any manner so as to become subj tom o e ompen Iron Laws of cell. All r -s ' e inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date — °(� Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Cods,you must forthwith comply pp p y p
with such provisions or this permit shalQbe deemed revoked source gulatlonS.
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 rO OV Dg Otbess"C"Ot better.
hereby authodm representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against Ilabllltlee,
judgments,costa and expenses which may In any way accrue against said City In consequence NA URE OF APPLICANT DATE
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 ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY '