R 5358 APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R- 5358
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' 24
- -
10-390
/ Lam' Ste' J72A �/(/ RESIDENTIAL COMMERCIAL v OTHER
OWNER'S HAZARDOUS FIRE AREA
//s
NAME ` c� 'D L. //LI (0(/J /j„� �'2 YES ❑ It yes s I understand that. Class A
( roof assembly is required.
NO ❑ Initial I.C.BA.#
ADDRESS EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
_ CONTRACTOR'S - r
NAME (A �S L�1i 1 TO BE REMOVED�_TO BE RETAINED n __
ADDRESS u (Y
j/ ) � ( n TYPE OF ROOF COVERING
EXISTING
PHONE y��- 3 - �i/ BUILT-UP ROOF [t}- Tl q
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSEDdunderCONTRACTORS f Chapter
9 N I
(c
1 hereby iaffirmnion that I em Business
licensed under Professions
ions of Chapter 9(commencing with Section WOOD SHAKES ❑
7000)of Division 3 0l the Business entl Prafeeslone Code,and my license Is In lull farce andeffec
License
D WOOD SHINGLES E] 3
License Class � � Lic.Number �q �)
Date — ( Contractor (/4 OTHER (SPECIFY) ❑
OWNERBUILDER 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 Of county which requires a permit to
construct,alter,improve,demolish.or repair any structure,prior to Its Issuance,also requlreq the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the tesla lar the alleged SQ ASPHALT SHINGLES ❑
• exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the a pliygnt t(U
e civil penalty of not more than five hundred dollars($500).): 1 •i ❑
❑I,as owner of the property,or my employees with wagesaethelrsole cg19'�1 Aral will do WOOD SHAKES
the work,and the structure is not Intended or offered for sale(Sec.7044,BOflnsea antl Prolea-
sions Code:The Contractor's License Law does not apply to an owner of property who bullm,ar r •"' WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own empl eea,p-mad that
such Improvements are not intended or offered for sale.If,however,the bndiZ or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER (SPECIFY) (�!�
not bund or Improve for purpose of sale.). `
El 1.as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors 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(a)licensed pursuant to the Contractors License Law. PROVIDE MFGR. INSTALLATION SPECS,
[II am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑l have and will maintain a Certificate of Consent to sell•insure for Workers Compensation, C.` I /�
as provided for by Section 3700 of the Labor Code,for the performance of the work for which IN ��?
7 [ SQV
Building 1-97
permit is issued, l/ �.�,
❑1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of r Seismic (v
the Labor Code,for the performance of the work for which this permit is Issued.My Worker's / Q�p
Compensation
Insumnce arrler and 'Policy number are: Total Zs__
canier__2TrP l/1 /Vl4TrL P.lICYNO, s ^ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N
(This section need not be completed If the permit Is for one hundred dollen($100)00)or IoesJ
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 su ject to the workers'Compensation caws of Cali- All roofs shall be inspected prior to any roofing material being
fornia, installed. If a roof Is installed without first obtaining an
Date 7-L1- gpplicant inspection,I agree to remove all new materials for inspection.
NOTIn
subject 2 the Workers'Compensatio p�ovsi beco
o afcheflcate of Laborr Codamyolu Musuforlthwlitth comply Applicant understands and will comply with all non point
with such provisions or this permit shell t de It revoked. source regulations.
I certify that t have read this application ends a that the above Information is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,entl All r0 COverl SIO be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentlansd property for In
spection purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against veld City In consequence G ATURE A P ICA DATE
ic
of the grantingof this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: V FINAL: j
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY