R 5357i
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OFFICE COPY
PERMIT R- 53577
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
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS - .
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10 L Z O � �y A (/'� �V /
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RESIDENTIAL-)C—COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
S,k £ (S E
YES ❑ If yes - I understand that a Class A
NAME (i ��l 1 •C/
root assembly Is required.
Initial I.C.B.O. N
1NO
I U I Z8 I6 Aw 9 SD I
EXISTING ROOF COVERING
ADDRESS O
PHONE Z 'S —
NUMBER OF EXISTING COVERINGS L
CONTRACTORS n/
NAME E S L 6V n.1 (��C I Irm
01�
TO 13E REMOVED TO BE RETAINED
ADDRESS2 I 41 1+..r• 9 �.// Z
TYPE OF ROOF COVERING
l fig.
CITY & ZIP J V
EXISTING
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PHONE 4 O Q` D— 9 f/ l
BUILT-UP ROOF ❑
LICENSE
NUMBER
ASPHALTSHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a (commencing with Section
WOOD SHAKES ❑
7000) of Division 3 of the Buslneas and Professions Code, and my license Is In full force and
effect.
License Claes C' Lic. Number O
WOOD SHINGLES ❑
-
S I —S P Lo WT E
OTHER (SPECIFY)
Date Contractor v w (2PGum,
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Lew 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 Ills a signed tom that Is licensed pursuant to the provisions
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of the Contractor's License Lew (Chapter 9 (commencing with Section 7000) of Division 3 of the
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Business and Professions 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
a civil penalty of not more than live hundred dollars ($500).1:
EJ 1, 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 (Sac. 7044, Business and Profes.
alone Code: The Contractor's License Law does not apply to an owner of property who builds or
Improves
WOOD SHINGLES ❑
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 said 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 exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not
PROVIDE I. W.,REPORT NO.
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 Contractor's License Law.
❑ 1 am exempt under Sec. ,B 8 P. C. for this reason
PRO 'tlIFTR. INSTALLATION SPECS.
dd
ownerDate
APPLIC 100 N' ATE UATION
PER FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:-
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❑ I have antl will maintain a Certificate of Consent to self -insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
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Building
permit is Issued.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
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Seismic
-the Labor Code, for the performance of the work for which this permit Is Issued. My Worker's
CompensatlP Insurance
TOtal
terrier antl Policy number are: _
C ti f L' l
PERMIT AUTHORIZATIONDAT
Carrier 1 kt /h1 A� Policy No C A Q f S'— 16
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.]
(This section need not be completed If the permit Is for one hundred dollars ($100) or IeasQ67
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 s lett to the Workers' mpenseilon Laws of Calb
All r0 . -ha a inspected prior to anytofi g mat rial UORW
forms.
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1— I C 8
installed. If a roof is installed without first obtaining an
Date 1 Applicant e�inspection,
I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, atter making t e ergficate of Exemptlon, you should became
subject to the Workers' Compensatlon provlsl e t the Labor Code, you must forthwith comply
A IiC comply p
pP • ant understands and will tom with all non point
with such provisions or this permit shaigbe de revoked.
Source regulations.
I certify then have reatl tole epplicatlon en tle le 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 class "C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
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(We) agree to save, indemnity and keep harmless the City of Cupertino against liabilities,
judgments, costa and expenses which may In anyway accrue against said City... consequence
of the granting of this permit.
IGNATURE OF AP ANT 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