R 5793 APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5793
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
1 B DAYS FROM LAST CALLED INSPECTION.'AS �1
d D /�/c , 5 L ,4 t. RESIDENTIAL COMMERCIAL OTHER
OWNER'S n .L HAZARDOUS FIRE AREA
NAME rl,Is7^ lJ NS O� C C./ -w y co VES ❑ If yea assembly I understand that a Class A
roof —Iundo is required.
NO ❑ Initial I.C.B4O.k
ADDRESS EXISTING ROOF COVERING
PHONE 3 7�'� ` NUMBER OF EXISTING COVERINGS
CONTRACTOR'S /J
NAME /AOS 40d"ClWa TO BE REMOVED TO BE RETAINED
ADDRESS p TYPE OF ROOF COVERING
CITY&ZIP/''O• dgr-,& /7 26 eoS lirl76s•• Ci¢ r�7� EXISTING
PHONE 3519'— 3 BUILT-UP ROOF ❑
LICENSE
NUMBER T Q ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES �.
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect WOOD SHINGLES ❑
License Claes G 3 / Lic.Number��``3
Date Contractor. OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I.am exempt from the Contractor's License Law for the following reason.
(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 file a signed statement that he is licensed pursuant to the prov1 a
of the Contractor's License Law(Chapter 0(commencing with Section 7000)of Division 3 t
• Business and Professions Code)or that he Is exempt therefrom and the basis for the aIle ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applic
a civil penalty of not more than five hundred dollars($500).):
[3 1,as owner of the property,or my employees with wages as their sole compensetlon,call tlo WOOD SHAKES
the work,and the structure Is not intended or offered for sale(Sec.7094,Business and Profen- Z
slons Code:The Contractor's License Law does not apply to an owner of property who builds or OOD SHINGLES A
Improves thereon,and who does such work himself or through his own employees,provided that W
such improvements are not intended or offered for sale.II,however,the building or Improvement p��Q
Is sold within one year of completion,the owner-builder will have the burden of proving that he did O (SPECIFY) Cn1 N\wO
net build or Improve for purpose of sale.). `(y
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractoes License Law does not PROVIDE I.C.B.O.REFOR 7
apply to an owner of property who builds or Improves(hereon,and who contracts for such projects .• 'f
with a contractor(s)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALIAT)O�1 SPECS.
❑I am exempt under Sec. ,S 8 P.C.for this reason
Owner oats
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
'
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-insure for Workers Compensation, Building /�7`ciV
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is Issued. Seismic ��l�C-�
C]I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
.the Labor Code,for the performance of the work for which this permit Is issued.My Worker's 00 �O
Compensation Inaurence carrier and Policy number aro: / Total
Carrier Af 6;;n Af �A7¢IOT Policy NO, A61L—DSIi'�5'DO PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed it the permit is for one hundred dollars($100)or IessJ Q- j{'�✓�
I certify that in the performance of the work for which this permit is issued,I shall not employ lIVJJ
any person in any manner so as to become subject to the Workers'Compensation Laws of Call. All roots shall be inspected prior to any roofing material being
.fornia. installed. If a roof is installed without first obtaining an
Date 5'1-91-98 Applicant �"r.w++'• Dd;.�t inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,alter making this Certificate of Exemption,you should become Applicant understands end will cont
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP ply with all non point
with such provisions or this permit shaifbe deemed revoked. SOUfCe regulations.
I certify that I have read this application and elate 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-mentioned property for in-spection ?/�
judgments,
purposes. �h91 V _ / �•�
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
lutlgmente,costs and expenses which may In any way accrue against said City In consequence -
ot the granting of this permit SIG RE OF 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY