R 5910 PERMIT R_ 5 910
APPLICATION FOR CITY OF CUPERTINO NUMBER
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
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME __L6 -f V✓L(.�� C- i YES 0 If yes—I understand that a Class A
( of assembly is required.
_ I , NO Initial C.B.O.IN
ADDRESS J 0R // EXISTING ROOF COVERING
PHONE 1 — o 3 L' NUMBER OF EXISTING COVERINGS
CONTRACTOR'S --� /� /
NAME `'� G i`Y `:/ • 19d /tC HG TO BE REMOVED TO BE RETAINED
CNazP /1 Za.0teMO �S1/y TYPE OF ROOF COVERING
[�/ G EXISTING
PHONE__L 0 0 '�'�5-� BUILT-UP.ROOF ❑
LICENSE El 2�
NUMBER ASPHALT SHINGLES
LICENS O CONTRACTORSsof Chapter 9(N
I hereby inion that I em Business
and
Pr lessons of Chapter a(commenting calif Section WOOD SHAKES dv
]000)of Division 3 of the Buelnesa entl Prolesalone Code,and my license Is In lull lone and '
effect. {y.(� WOOD SHINGLES "
License Claes Lie.Numbar
�L OTHER(SPECIFY) ElDate Contractor '
OWNER BUILDER DErs License
N PROPOSED
hereby affirm that I am exempt from the e: Any
License Law for the requires
a reason.
(Sec.]ct,alt Business and Professions or re Code: Any city or county which e,also
a permit to
construct,alter,Improve,to file signed statement
ementrthat he prior Colts Issuance,ate orequirea the BUILT-UP ROOF ❑
applicant for such permit le flaw fsignetlr 9(cmemthatg with
pursuanttpthe provisionsoth
of the Contractor's License Law(Chapter a(commencing with Sectlon 7000)of Dlvlalon 3 of the
•
exemption.
and violation of Code)or that he Is exempt therefrom and the bests for the altegftl ASPHALT SHINGLES
exemption.Anyt violation more
of than
five
hundred
by any applicant fora permit subjects the applicant to
e dull penally of net more then Ilva hundratl dollare(5500).):
❑I,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 Proles- SHV
A
alone Coda:The Contractor's License Lew 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 �CrD ❑
such Improvements are not Intended or offered for sale.If,however,the building or Improvement �p� J
Is sold within one year of completion,the owner-bulider will have the burden of proving that he did OTHER(�PELI E]not build or Improve for purpose of sate.).
1,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(See.70",Business and Professions Code;The Contractor's License Law does not PROVVEA.C!B.0�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 Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
ElZ/ �.
I have and will maintain a Certificate of Consent to self-insure for Workers Compensation, / // Building d6
permit
mitprovided for sued. Section 0700 of the Labor Code,brine performance of the work for which mla � dtj
ormit ie Issued. C9 l /� U �a v Seismic
have entl will maithe performance
Worker's Compensation the work
which this as repulsed by Section Worker's of
the Labor Code,for the pander ance of the work lar which Iola permit Is Issued.My Workers -7�-7� T�(y^�/
Compensation Insurance tamer and Policy number ere: Total / ,
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N,C.ID p /�
(TMs section need not be completed If the permit Is for one hundred dollare($100)or leas.) O T ,,/_ '] y
I certify that In the performance of the work for which this permit Is Issued,f shell not employ 2/ _ lfl Li l
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell. All roots shall be inspected prior to any roofing material being
ferrle. &... ✓ installed. If a roof is installed without first obtaining an
GG L' ar r/r R �n1 c 1d inspection,l agree to remove all new materials for inspection.
.Deter✓ET APPlimaki 4s 6a tits, P 9 P
NOTICE e A Ls'Com If,atter making this f the
of o ,youExemption,you shouts become Applicant understands and will comply p
withssubject to the Workers'or Compensation l be d one d iha Lebon Code,you must forthwith comply PP ply with all non Olnf
with such provisions or tole permit shell be deemed revaketl.' SOUfCe 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 comamctlon,entl All rgof coverings to be class Or tter.
hereby authorize representatives of this city to enter upon the above-mentioned property for im /C/Ji/ /
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, �r 11. 1A T X
judgments,costa and expenses which may In any way accrue against said City In consequence
of the granting of this permit. SIGNATURE OF APPLICANT 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
OF IF ICE COPY