R-5714 PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5714
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408)777-3226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
.&Y10 (��� fJ �( ,{J RESIDENTIAL V COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
/,— n rl ,y //1 ./ L .—s��� ,, ,r YES ❑ If yes—I understand that a Class A
NAME A`111u—M114z7 /V/7/ 119 71L�7rr+�iY//Y-7 t/ roof assembly is required.NO Initial I.C.B.O.N
ADDRESS �/�l3 �'(J1�lV�/�/�///F! �`CL//�t1�1� EXISTING ROOFCOVERING
PHONE �Dr�� 3 � O /! NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME TO BE REMOVED TO BE RETAINED
ADDRESS .{ _ TYPE OF ROOF COVERING
CITY&ZIP 727 r/
EXISTING
PHONE // d -(Z�fj�l BUILT-UP ROOF ❑
LICENSE
NUMBERJ ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby affirm that I em Business
licensed under Professions
of Chapter g(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professlona Cotle,and my license Is In full lone and /
effect. WOOD SHINGLES
License CIaa4 Llc.Number � j�
Date &42:1Z Contractor 4A Y L 2Z OTHER(SPECIFY) LY
OWNER-BUILDER DECLARATION PROPOSED �Q
I hereby affirm that I em exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to V �
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOFO ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Lew(Chapter g(commencing with Section 7000)of Division 3 of the —A`6
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHAII 1 LES �\Vo
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to �a— t��
a civil penalty of not more than five hundred dollars($500).): VJ
01,as owner of ma property,or my employees with wages as their sole compensation,will do WOOD GI�9K�s ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Prolan
slons Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES El
thereon,and who does such work hlmseif or through his own employees,provided that
such Improvements are not Intended or offered for sale.II,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the bu rden 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 Prolesalons Code:The Contractor's 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 contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
C]I am exempt under Sec. ,S It P.C.for this reason
owns, 1Z X Dere Qbe/•
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 sell-Insure for Worker's Compensation, BUIIdi
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /�
permit Is Issued. o' " 9v ? Seism
❑I have and will mainttn 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
Compensation�In,,s'urance terrier and Policy number are: .f s(�pJ1T Jy✓I TO.-I
Carrie J'R�t /r//?/N6tZP-1 1poiicyNo.G��L ry �V PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' I
COMPENSATION INSURANCE N.C.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 Cell. All roofs sh4l be sp cte for to any roofing material being
fornia. installed. If a r of is installed without first obtaining an
Date Applicant inspection, I agree to remove all new materials for inspection,
NOTCE TO APPLICANT: If,she,makbecome
subject il.the Workers'Compensation proivisionls ofathe lLabor Code,Exemptof lu onmust fo thwilth comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. 4IGNATURE
regulations.
I certify that I have read this application and state that the above Information Is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction.andcoverings to beclas rbetter.
hereby authorize representatives of this city to enter upon the above-mentioned property for Im
spection purposes.
(We)agree to save,Intlamnify and keep harmless the City of Cupertino against Ilabllltles, —
judgments,costa and expenses which may In any way accrue against said City In consequence
of the granting of this permit. 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY