R 5809 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5 8 0 9
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
1 RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES [:] If yes-I understand that a Class A
NAME _ 07ANA IY 10012E roof assembly is required.
NO ❑ Inial I.C.B.O.e
ADDRESS SAME A'S A150-JE EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S /� --7t`Ooh-3N
NAME OS GATos V TO BE REMOVED ^ TO BE RETAINED
L
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP 1,7-11 ` M-STH AJE. y �JAn1 TasE EXISTING
PHONE BUILT-UP ROOF . ❑
LICENSE p
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect. �syt WOOD SHINGLES
License Class �+ • Llc.Number d•� 31/& ❑
-{�
Oats 02.-A-10-98 Contractor ��� D-�sav"s-- OTHER(SPECIF ❑
OWNER-the Conn DECLARATIONrsLicense
PROPOSED
1 hereby affirm Ines am exempt from the e: Any
License taw for the following reason.
I ID
(Sac.70315,r,Improve,
and demolish,
or rep Code; Any city or county which requires a permit to
applicconstant
eller,Improve,tofile a signed statement
air eny menthatstructure,in licenseor to Issuance,pursuant also requires the BUILT-UP ROOF
appllcent lar such permit License fila a elgned r 9(co m nci g le licensed pursuant to the proof the
of the Contractor'sstonLaw(Chapter a(commencing with om and 7000)of for the 3 of the �� ® �
Business and Professions Code)or that he Is exempt therefrom and the baste for the applicant
to
ASPHALT SHINGLES
exemption.Anyviolationnot of than
7031.5 by any applicant for o permit euDJede the opplicanl to
e dull penalty of not more peen floe by employees
yees with
wages
ag); WOOD SHAKES �y
❑I,k,and wner
sthctureI not
tended oyeeeredh r sate(Sec.7 sole compensation,sndPr ll do CITY (�PUI't;.h L144V/
the work,antl the structure la not inse Law or s not for rile n owner
of Business and Profess V
Ilona Code:The Contractor's es such Law does s 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,Improvement provided that
such Improvements are not intended or offered for sale.ill however,the hulloing or ImprovementIs sold I
not
thinor
prove for purpose
stheowner-builderwill have the burden 11provingthat hedid 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(See.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner f property who builds or Improves thereon,and who contracts for such project.
with a contractor(.)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
E]I am exempt under Sec. ,B&P.C.for this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perlury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, BUlldln
as for by Section 3700 of the Labor Code,for the performance of the work for which this v �� / g -�
permitmit Is ie Issued. 0
[DI have and will maintain Worker's Compensation Insurance,as required by Section 3700 of / Seismic rf�
the Labor Code,for the performance of the work for which this permit Is Issued.My Workers Qom) y
Compensation Insurance carrier and Policy number are: y _7,
Total _'"s
Carrier AME2icAW 1�#&Wi 2r Z0(AAl1.Policy No.S 9 QS6 2E_- 0 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATIONIftheINSURANCE 100)o
(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.I shall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali. All roofs s e inspect6ld prior to any roofing material being
fornia. Cuu. ;7 instal . If a roof is installed without first obtaining an
Date 01- %o - /P Applicant n��- L44417 — insp 'tion,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,ager 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 Code,you must forthwith comply PP- P Y
with such provisions or this permit shalCbe doomed revoked. Source regulations.
certify that I have read this application and state that the above Information Is correct.I agree
Io 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 me above-mentioned property for In. \\
apache)purposes.
(We)agree to save,penesIndemnity and keep hay lessway the Clry of Cupertino y Inagainstcon liabilities,ence (�^(•24-r1B
Judgments,coals and expenses which may In any way accrue against said City In consequence SIGNATURE OF APPLICANT
of me graining of mis pelma. 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