R 5393PERMIT R_
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APPLICATION FOR,. CITY OF CUP9RTINo - NUMBER 5
-., INSPECTION DIVISION PERMITEXPIRAnoN
REROOF PERMIT (406) 777-3228 PERMIT EXPIRES'IF WORK IS NOT STARTED
- WITHIN 100 DAYS OF PERMIT ISSUANCE OR
190 DAYS FROM LAST CALLED INSPECTION. '
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL - OTHER
OWNER'S
VJ/,/:j
- •,� HAZARDOUS FIRE, AREA ..
t . ..
YES ❑ If yes — I understand that a Class A
NAME IOS/ �^^ L�^+�J� /V. Y�OJY�.�..
roof assemdy is required: _ ',
NO :.Iridal' ; LC.B.O. #
- YYY
ADDRESS- ` i CJS'
-. 5EXISTING ROOF COV
..
NUMBER OF EXISTING COVERIN
+ ..
�
PHONE 'oq tDa
CONTRACTOR ^� ,r-� /f
CCS' ritJ Jh/JJ�G`^J ,/1•';
NAME /
TO BE REMOVED ' TO BE RETAINED
ADDRESS '
/•� ��/1�
TYPE OF ROOF COVERING
'''-
CITY & ZII h / /1_%l�
EXISTING
'PHONE'•
BUILT-UP ROOF. ❑ '
LICENSE ^1/ �t., • ,°'
NUMBER.. ' pfl(/
- i -
I SHINGLES
-
" LICENSED CONT OLA I
-1 hereby affirm that I am Ilceneetl under I r o� -ep 9 mme n It action
• OD AKES - '. ❑ •-
7000) of Division 3 of the euslnesa entl Pro alone Cod my I rise' n I 1 n
effect. n
INGLES
V
License'Cless `--� LicN
,,Date
-Contra
IS
P 9
OWNER BUIL
A
cnsN
a permit t,.
hereby affirm that am exempt from the Code: city License Law for the requires
Cotle: Any city or county which requires a permit to
Business and Profedemolish,
' (Sec. 7ct,
PROPOSED
CT Q'
aft or rep air eny mentrthat he prior tolls Issuance. pursuntaleenquires the
applicant for such permit flaw a signed
appllcconstruct,eltar,Improve, to file asigned statementthat he Is licensed pursuant to the provisions
BUILT-UP ROOF Fi A�
of the Contractor's a r 9 (commencing
License Law (Chapter S (commencing with Section 7000) of 3 the
the
nn (�
� Li I r Ur
and • Code) or that he Is exempt and the bawls for the
for the le
ASPHALT SHINGLES LUh
AiNV,
exeminessption. antforam
exemption. Anyf violation
violation of
of Section 7031.5 by any applicant for a permit subjects the applicant to
applicant to
'
more
e civil penalty of not more then five hundred employees wag.):
dollen with
❑Irk, owner oyeeered wegee as Bole compensation,sand
WOOD SHAKES V
❑ „
structure (Sec.their
the work, and the structure Is not Intended or offered for eels
i not I tended Business entl Prolf s.
-
amoreCode:The, anwho des such Lewdoes not apply toenowner of property who builds or
n ow er of mads or
Improves thenen, entl who does work himself or through his own employees, provided that
WOOD SHINGLES ❑ j '
such Improvements are not Intended or offered for sale. If, however, the building or Improvement
- -
Issoldwithinoneyearofcompleticn, 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.C.B.O. 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 Lew. -
❑ I am exempt under Sac. ,B & P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Date
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 Worker's Compeneetlon,
-. •
BUI ding)
as provided for by Section 3700 of the Labor Code, for the performance of the work forwhlch this
B l$sOed.
p have
101�/�
,g �7$eISfI11C
entl will maintain Worker's Compensation Insurance, as required by Section 3700 of
L
lam✓
th 1
or Code, for the performance of he work for which this permit Is Issued. My Worker's
!
Cc pe I Insu ane c j end8P y numoer arm.
, �
Total
Carder ky-0 Pollc�riTc ,
PERMIT AUTHORIZATION
DATE `
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N,O.❑
'- (Thaw section need not be completed If the permit la far ane hundreddollars ($100) or less)
I certify that In the performance of the work for which this permit is Issued, I shell not employ
. All roofs shall be ierspected prior to any roofing m terial being
any person in any manner so as to become subject to the Workers' Compensation Lew o Can-
joint - p
f�.�97 ..
installed. If a roof is installed without first obtaining an
Dat Appl
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, after making this Cer •at of Exemptlo , you should become
subject to the Workers' Compensation provisions of t Labor code, you most forthwith comply
Applicant understands and will 'Comply with all non point,
with such provisions or this permit shalgbe deemed revoked:'
SOUfCe regUlafIODS.
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 to COV trin } e "ror better. - -
hereby authorize representatives of this city to enter upon the above-mentioned property for In.,
spectlon purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities,.
judgments, costs and expenses which may In any way accrue against said City.. consequence
of granting of this permit.
'S NATURE OF APPL DATE -
PRE -INSPECTION:
PLYWOOD: -.- -,
IN -PROGRESS:- .,--
INSP. DATE
'INSP. DATE -
INSP. ' - - DATE
TEAR OFF INSPECTION:
BATTENS: - -
FINAL:
JNSP.` - DATJo ZOO,
INSP. I DATE
INSP. DATE
.'.'NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
?. "� OFFICE COPY'