R 5859 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR: 5859
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
IP
180 DAYS FROM LAST CALLED INSPECTION.
UILDING ADDRESS\ n
I V F0 �IC• RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME /,f IL L E l' YES ❑ If yep —I understand that a Class A
roof assembly is required.
�'R ^ q NO Inidal I.C.B.O.N
ADDRESS 74 '7'`� +�c� �O{� DR • EXISTING ROOF COVERING
PHONE OS/ U NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME ClL / . KI G�k TO BE REMOVED TO BE RETAINED
ADDRESS 9 l '�4D8� fYPE OF ROOF COVERING
CITY B ZIP 106 PL . :%..q t{Ly4•& yr
/ ` q EXISTING'
PHONE L y0$J !�lo '�5�� BUILT-UP ROOF ❑
LICENSE
NUMBER S�Ti3 L ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is in full force and /
anew. WOOD SHINGLES El
DaClass Ua.Number
Date
Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am 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
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 provisions
of the Contractor's License Law(Chapter a(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit Subjects the applicant to
e civil penalty of not more than five hundred dollars($500).1:
E]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 Profes-
slonsCode:The Contractor's 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 El
such Improvements are not intended or offered for sale.If,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) El
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 contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B 8 P.C.for this reason
Owner Data APPL CATI9Il VALUATION PERMIT FEE
' WORKER'S COMPENSATION DECLARATION
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, Pang
din
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 1 `it7 g
permit Is Issued. ®
[31 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of O•-R Seismic
,the Labor Coda,for the performance of the work for which this permit Is Issued.My Worker's
Compensation Insurance carrier anD number are: or Ct:Nl ll �� 0
) Total
STQ'/ y
Carrier ATE Policy Nol,
PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(This section need not be completed If the permit Is for one hundred boilers($100)or lose.)
I certify that in the performance of the work for which this permit Is Issued,I shall not am to
any person In any manner so as to become subject to the Workore'Compensation Laws of Llan- All roofs shall be inspect d prior to any roofing matedbe' g
forma' installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shelPba deemed revoked. source regulations.
I certify that I have reed this application and state 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 Wverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-merdioned property for In- r
sp(Vian purposes.
(W _mss `('ivy 1
e)agree to save,expenses
and keep in an way the City ai Cupertino against IIabIIonue (•/( 7 CxJ
judgments,gran,costs and expanses which may In any way accrue against ealtl City in consequence
of ins granting of this permit. SIGNATOR LIC NIT . 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