R 5363 e
PERMIT f
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5363
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 QQ /
G RESIDENTIAL - COMMERCIALy OTHER
OWNER'S _pHA RDOUS FIRE AREA
NAME Ll ✓l Gr!/�J d �O L Ai /IL YES ❑ roof assembly stand requiireda Class A
NO ❑ Initial I.C.B.O.M
ADDRESS EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRALA)
CONTRACTORS
4SN R'S ^/ Oma!
NAME T E IL (�P G I 11A qti L.;, TO BE REMOVED v TO BE RETAINED _
ADDRESS U \13 TYPE OF ROOF COVERING. "T
clTvazlP- 2-?) Y17rI- �2& �r �ij fS//Z
EXISTING
PHONE `{I — 3 6 e — t t BUILT-UP ROOF
LICENSE ❑
xNUMBER ASPHALT SHINGLES
LICENSED
underCONTRACTORS DECLARATION ❑ T � A�
hereby affirm that em Business
nestl under Professions
of Chapter g(commencing with Section and WOOD SHAKES ZVx/J
7000)of Division 3 of the Buslness antl Profssslons Code,and my license s in lull lode entl
effect. WOOD SHINGLES ❑ ��
License Class {_ Llc.Number 6 7 ""
Dela 7 'f�' Q con actor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that I am exempt from the Contractors License Law for the following reason.
IS
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 provision:
of the Contractor's License Law(Chapter 8(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the bass 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 five hundred dollars($500).):
El 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(Sec.7044,Business and Press-
slons Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES
improves thereon,and who does such work himself 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 burden of proving that he did OTHER(SPECIFY)
not build or improve for purpose of sate.).
[11,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 Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APItII`N,I NDATE VALUATION PERMIT FEE
I hereby affirm under ponaity of perjury one of the following declaration: _
❑I have and will maintain a Certificate of Consent to sell-insure for Workers Compensation JUL O nMllrD Building
r as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which thio u f11'I17 ry ��� �•�
permit is Issued. (% Seismic
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 0l I �
r the Labor Cotle,for the Pedermance of the work for which this permit is issued.My Workers L TY Ur IxUYCh I IIVU .(
Compensation Insurancl carrior antl Polic�y'}nyZ ere: Total • V
Carrier e_lAr,Pnw Q[fN �1�1 I— Pallcy No
q l S1" Ill PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the permit is for one hundred dollars($100)or lees.) `7-1,9,-3V
I certify that in the performance of the work for which this permit Is issued,1 shall not employ
any parson In any manner so as to become subject to the Workers' ensatien Law,of Cali. All rootf,s all be inspected prior to any roofing material being
fornix' installed. If a roof is installed without first obtaining an
Date 7—/a—9,�, Appucam inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after maki 1 I,Certificate of Exemption,you should become Applicant understands and will comply
-subject to the Workers'Compensation pro late a of the Labor Code,you must forthwith comply PP ply with all non point
with such provisions or this permit sha l). tie ad revoked. Source regulations.
I certify that l have read this application a tate that the above Information is correct.I agree
to comply with all city and county ordinances and state laws rotating to building construction,entl lroof C Brings to SS"C"or better.
hereby authorize representatives of this city to enter upon the above-menllonetl property for In-
,spectionpurposes. A
(Wel agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, Y
judgments,costs and expanses which may In any way accrue against said City in consequence
of the granting of this permit. SI ATURE OF APPLICANTDATE
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 f