5549 APPLICATION FOR CITY OF CUPERTINO
NU BERPE - 5549
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1Be DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS{.
S tSQV%k CFL Ar— RESIDENTIAL_ COMMERCIAL OTHER
OWN R'S HAZARDOUS FIRE AREA
M� } ZS 1 _ _ . YES ❑ If yes-I understand that a Class A
NAME "`"1�t L OCKN roof assembly Is required.
y� `� NO ( Initial I.C.B.O.4
ADDRESS frill LS"t K@ -i ilfili EXISTING ROOF COVERING
PHONE L400 -7'30- IS V�L NUMBER OF EXISTING COVERINGS ' I
s
CONTRACTORS
' `n
NAME Il 1-,J Tip FG`?2m I�EVe Lor-'ME1�T TO BE REMOVED I TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP 574-3 C:HESe�tt��� � C 3S,2'951�3
• \ EXISTING
PHONE og� egg-g4B4 BUILT-UP ROOF ❑
LICENSE ❑
NUMBER 1a SSia ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is In lull force and
effect.
License Clara INumber SS WOOD SHINGLES ❑
Date
0 9.7 Contractor +� A � OTHER(SPECIFY)
❑
�.... -
OWNER-BUILDERContra DECLARATION PROPOSED
1 hereby affirm that f am exempt from the Contractors License Law for the following reason.
(Sec.7ct,alt ,improve,
and demolish,
Professions Coda: Any city or county which requires a permit toconstrC /
applicant
alter,improve,to file asigned statement
anystructure,prior to Its issuance,to rhorequiresprovisions the BUILT-UP ROOF ❑
applicant for such permit a flaw a signed r 9(comm that he is licensed pursuant to the provisions
of the ss and
License Lew(Chapter h(commencing with Section 7000)of Division 3 of the YY
Business entl Professions Coda)or that he Is exempt therefrom and the bees for the alleged ASPHALT SHINGLES L♦U •CL-K..
exemption.Any violation of Section hundred
by any applicant for a permit subjects the applicant to
e cion penalty of net more men Ileo hundred aoas (h wage: WOOD SHAKES ❑
❑I,as owner al the property,or my employees with wages as their Bole compensation,will tlo
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
sions Code:The Contractors License Law does not apply to an owner of properly 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.It,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 safe.).
❑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 contrachl licensed pursuant to the Contractor's License Law. PROVIDE III INSTALLATION SPECS.
E]I am exempt under Sec. ,e&P.C.for this reason
Owner Date APPLICATIO DTE 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 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
I permit is Issued. J- Seismi
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of G/L•x'�
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's Cp�� � Total
Compensation Insurance carrier and Policy number are: l
ler Policy No. PERmifAVOHORIZATION
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.(:]
(This section need not be completed If the permit Is for one hundred dollars($100)or fess.)
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 subject to the Workers'Compensatlo Lawa wl coli- All roof^shallbe iritpetted prior to any roofing material being
fornix. o installed. If a roof is installed without first obtaining an
Date e7 hT Applicant inspection,I agree to remove all new materials for inspection.
y subecctIotheOWorrkers'Compefn9llonprovisionlsofthelLabor Code,yolumusttforthwith Dcomply Applicant understands and Will comply with all non point
with such provisions Or this permit shafte deemed 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 building construction,and All roof coverings to be class"C°Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes. n t
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, 1,� S�g[4 �,
C J I,
�E
judgments,coats and expenses which may In any way accrue against said City In consequence
of the granting of this permit. SIGNATURE OP APPLICANT DA
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