R-5598 APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R- 5598
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
'
WITHIN DAYS PERMIT ISSUANCE OR
WI DAYSS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS ) 1X/
VV/ l/q RESIDENTIAL' ` COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
[)�.��l �j/b �-/� VES ❑ If yes-I understand that a Claw A
NAME �0`-'t"' 1 ,i/x o A'sa- , roof assembly Is required.
` NO ❑ Initial I.C.B.O.
ADDRESS al4lti -c/ Gr]cr✓ � \i EXISTING ROOF COVERING
PHONE Q I 3 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S TO BE REMOVED 9101fl TO BE RETAINED
NAME J/ /i GC'j'1 III
ADDRESS C� / 37� TYPE OF ROOF COVERING
CITY&ZIP 77 / �/��
9� EXISTING
PHONE S-32- 65"�za^ BUILT-UP ROOF ❑
LICENSE
NUMBER 5z-r ASPHALT SHINGLES ❑
LICENS d underCONTRACTORSsof Chapter 9(N
hereby affirm that am licensed and
Pr provisions al Chapter 9(commencing with Section WOOD SHAKES
]0001 0l Division 3 0l the Business and Professions Code,and my license is in lull force and
enact.
_ fyWOOD SHINGLES El
License Class C / Lic.Number - __�
/O.3-yam OTHER(SPECIFY) ❑
Date - Contractor ti
OWNER-the onRDECLARAT PROPOSED �3 f
hereby affirm Ines am exempt from the e: Any City License Law r the following reason. /Q
(Sec.]ct,alt Business and Professions Code: Any city or county which requires a permit to
construnLorsuimprove,to file signedrepair statement that
prior toIts issuance,alsoreprovisthe BUILT-UP ROOF ❑ %
applicant for such permit to lila a signed statement that g itlicensetl pursuant to the provisions
of the Contractor's License Lew(Chatter h(commencing with Section]000)of for the 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 hundred
by any applicant for a permit Subjects the applicant to
a civil penalty of not more than five y employees
dollars with
wage WOOD SHAKES C,r, �
❑I,k,and
er the structure
turaisproperty or tended oyeffered wages as their(Sec. Bole compensation,snProfes-
sions
s- I !`
the work,end the structure is not intended ores not for sale(Sea owner
of Business end Profes-
iionovesth The Contractor's License workhi snot apply to an rthroughhiso own
property es,who
rovidebuilds or WOOD SHINGLES ❑
improves thereon,and who doessuchwork himself or through his own employees,Improvement provided that
such improvements aro not intended or offered for sale. ill however the the enbuilding or Improvement
nsold tbuild or
prove for purpose
sthe owner-builder will neve the burden of proving that he tlltl OTHER(SPECIFY) ❑
not build or Improve for purpose of Bale.).
❑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 Law. PROVIDE MFGR.INSTALLATION SPECS.
F7 am exempt under Sec. a 8 P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
EJ '�7
I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Q
permit is issued.and / ^ Seismic
❑ have and will maintain Worker's Compensation Insurance,as required by Section 3700's ( V I / m
the Labor Code,for the performance of the work for which this permit Is Issued.My Workor's Total !J
Compensation Insurance carrier end Pol�ic/Y,number are. G
Carrier �` ' '( ells"� Policy No. ^ -7.4/4`--57 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ �-r p ✓f
(This section need not be Completed If the permit is tar one hundred dollars S1 00)or less.)
I certify that In the performance of the work for which this permit Is issued,I shall not am ploy 1
any person in any manner so as to become sublact :,die workers compeneabOn Lew:of Ceg- All roofs shall be inspected prior to any roofing material being
forma `22
r, installed. If.a roof is installed without first obtaining an
Dat/6-]g /2 Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after makin is Certila of E mptlon,you should bqppm CQ Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Dor Co ,you must Iq[t�ultt/Irlpl
with such provlslons or this permit shell be deemed revoked, ffiorr11j)-0
0 source regulations.
I certify that l have read this application and state that the above lnformatio ect.I agree
to comply with all city and county ordinances and state laws relating to building construction,ano ltNJAZAJUPE
overings to be Class"C"or better.
hereby authorize representatives of this city to enter upon the above.mantiopp9ILWuj rtydoNin-
spection purposes. VL1I
(We)agree to save,indemnify and keep harmless the City of Cupertino against habllitles,
judgments,costs and expenses which may In any way accrue against said City in consequence PPLICANT DATE
of the granting of this permit.
INV 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