R-5658 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5658
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
• BUILDING ADDRESS 160 DAYS FROM LAST CALLED INSPECTION.
J�
cf�5 �OV� RESIDENTIALJ•y/
�COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
�illich nA Sb1Ae\\'x�.. .-. An VES ❑ roof assembly
isrequirad. ClassA
NAME l U1\ 111 AAA ` G 1 l�)� roof assembly is required.
_ NO ❑ Initial I.C.B.O.p
ADDRESS °r'6t-���n�rove. EXISTING ROOF COVERING
PHONE 40 51 - 3 NUMBER OF EXISTING COVERINGS '
CONTRACTOR'S ^
�4p ar)n ..,n \ln� TO BE REMOVED TO BE RETAINED
NAME— C. til' Y /`1� Y [
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP —I b � n.Ei15�'O�C1 Q4043
(coq-(off `Z� Mo�h3{nn V�te�
PHONE EXISTING
BUILT-UP ROOF
LICENSE UASPHALT SHINGLES
NUMBER ❑
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
effect.
C-1
90 WOOD SHINGLES ❑
Licens Close `� Lid.Number 54
al Ifo -0-1 RATION bit wF'ns OTHER(SPECIFY) ❑ ---
Date Contractor
OW from BUILDER DECLARATION PROPOSED
hereby affirm that am exempt from the Contractor's License Lew for the requires
a reason.
(Sec.construct,
It Business and Profedemolish,
or rep it any Any city or county which requires a permit to
construct,altar,improve,demolish,or raper any structure,prior to Its Issuance,also reproves the BUILT-UP ROOF [�]'
applicant for such permit to file a signed r statement m that g is licensed pursuant to the provisions
• of the Contractor's License Law(Chapter h(commencing with om Section 7000)of for the 3 01 the r"p
Business and Professions Code)or that he is exempt therefrom end the bests for the applicant
to ASPHALT SHINGLES �-1.� D
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the appllcenl to
a civil penalty of not more than flea hundred employees with
(h wage:
[11,k,and
er the structure
I not I my tended oyeffered wages(as Sec.their sole compensation,sand
Profits.
do WOOD SHAKES .S P 17 n{pT1
the work,entl the structure Is not Intended or offered for sale(Sec.7044,Business and Proles- IIICCUU U
cions 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 are not Intended or offered for sale,if,however,the building or improvement C
f V
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY)
CIT
not build or Improve for purpose of sale.).
❑I,as owner of the property,em 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 Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
E]I am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: c1
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, n„j-�.,Oscr- ,�, p I 1 L) C—' Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this l..C.t V V
permit is issued. Seismic9U
STbave and wl11 maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit Is issued.My Worker's 117, S r
Compensation Insurance carrier and Policy number are: Total
:Carder, C=10W_Ael I' cQgkQ- PoticyNo. NWC ryl PERMIT AUTHORIZATION DATE
CERTIFICATE OF XEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need not be completed if the permit is for one hundred dollars($100)or less.) - C 3 �y
I certify that In the performance of the work for which this permit is Issued shell not employ O
any person In any manner so as to become subj9pt to the Workore Compeneston Laws of call- All roots shall be inspected prior any roofing material being
fertile'`/�� Iinstalled. If a roof is installed without first obtaining an
Dare — 1-1`✓— Applicant _A0 n4 ,"'V inspection,I agree to remove all new materials for inspection.
NOTICE TO subject to the Workerss'Compensation provisions of the Labor Code yolu must forthwou ith become
comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed invoked, Source regulations.
I certify that I have read this application and stale 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 ro f coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
apache)purposes.
(We)agree to save,Indemnifyand keep harmless the City of Cupertino against liabilities,
judgments,costs and expansespenseswhich may In any way accrue against said CIN In consequence
pfthe granting ofthis 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
____ _ OFFICE COPY