R 5240 PERMIT R_ 5240
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (406)777-3226 PERMIT EXPIRES IF WORK IS NOT STARTED
-
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS / l �
RESIDENTIAL COMMERCIAL OTHER
' �" y HAZARDOUS FIRE AREA
NAME J' G �" t�(��n J prw VES p If ye -embly strequ led. ClassA
r� NO ym�rCbt Initial I.C.B.O.#
ADDRESS . 2671 C'oitward Wu EXISTING ROOF COVERING
PHONE oZS — `icvc' NUMBER OF EXISTING COVERINGS
CONTRACTOR'S TO BE REMOVED
y� 1 TO BE RETAINED v
NAME J x�ltvi� N• S�'1'I �1 y'• t
Nh '
ADDRESS TYPE OF ROOF COVERING
CITYaZIP 2`1°( 71 �6� f'F S.S . °(Sifp
EXISTING
PHONE_CLf94 �-771— 60-0 BUILT-UP ROOF ❑
LICENSE r
NUMBER toe 9 1'y" - ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
U78ga- �� C WOOD SHINGLES L�
License Class Lic.Number
Date t lZU9L Contractor ,,�e OTHER(SPECIFY) ❑
OWNER-theConRDECL License
PROPOSED
hereby affirm that I em exempt from the e: Any
or sous Lew for the fallowing reason.
(Sec.7ct,alt ,improve,
ve and Professions Code: Any city or county which requires e permit to
construct,alter,improve,to file siorrepeatenystructure,prior tope Iseuancs,also requires the BUILT-UP ROOF g/
applicant for such permit a fila a signed statement that g it licensed pursuant to the provisions the CJ
of the ss an Pro License Lew(Chapter 0(commencing with Section 7000)of for the ale the
Business end violation Of Code)or thet he Is exempt therefrom and the heels 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).):
❑I,as owneronhe property,or my employees with wages as their sole compensation,will do WOOD SHAKES L_ /(�(�j5 •G
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
sions Code: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 ❑
such Improvements aro not completion,
leb n,or offered for eels.I(however,the buildingof pr or Improvement
)a sold not
thinor
prove for purpose
sthe owner-bulldar will have the burden of proving that he the OTHER(SPECIFY) ❑
nol build or Improve for purpose of eels.).
❑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 dose 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. PROVIDE MFGR.INSTALLATION S
E]I em exempt under Sec. ,S&P.C.for this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: tJ V
E)I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, BDIId10
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this �� g�3 7
permit)ae and II/6/ I' 060 Seismic
eve entl will the performance
Worker's Compensation Insurance,as permit Is I su section Workers s /
t L or Code,for the performance of the work for which this permit Is Issued.My Warker'a
Compensation I su.,Irafoes carrier and Polley number are: J{ Total
Carrier I'CIG Policy No. �T✓L190 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be Completed If the permit Is for one hundred dollars($100)or less.)
I certify that 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 lett to the workers'Compensation Laws of call. All roofs shall be inspected prior to any,roofing material being
fornle. installed. If a roof is installed without first obtaining an
Date k < 6 (cant +-' inspection,I agree to remove all new materials for inspection.
NOTICE PLICAN . It after makin t oam become Applicant understands and will comply with all non point
subject to the Workers'Compansetlon proviela of the Labor Ctla,you must brthwith comply PP p y
with such provisions or this permit shall be deem revoked. source regulations.
I certify that I have read 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 bulltling construction,and All roof verings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes,
(We)agree to save,Indemnity and keep harmless the City of Cupertino againstIlabllltles, C 6 9
judgments,costs and expenses which may in any way accrue against said City In consequence
of the granting of this permit. ANT 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