R 5790 PERMIT R. 5790
APPLICATION FOR CITY OF CUPERTINO NUMBER
R,
PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
130 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS L•
6 (!)C:) / e&/�C.✓� RESIDENTIAL COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class A
NAME V-72d / C/GC of
assembly is required
07 NO ❑ Initial I,C.B.O.N
ADDRESS +t�CC7O /t—iT� B/riyCw� EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAMECl��/SY
ADDRESS �O r OX 3 SS'83 1c2S „r> TYPE OF ROOF COVERING
ary a nP
EXISTING
PHONE 4;"0'6' BUILT-UP ROOF
LICENSE
NUMBER 622 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Sectlon WOOD SHAKES 97��r
7000)of Division 3 of the Business and Professional Coda,and my license Is In full force and
effect.
0 39 G y9 z�— WOOD SHINGLES
License Class Lic.Number
Data sus`fib' Contractor /-A�/�= OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm Bu that am exempt fromns the Contractor's or roue Lew for the lino a rasion.
(Sec,70315, ,Improve and Profedemolish,
or rep Cade: Any city or county Issuance,
requires requires permit to
construct.altar,Improve,demolish,or rapaa eny nt that e,prior to Its lea rsuant alsoeprovii the BUILT-UP ROOF a
applicant for such permit License flaw a signed statement that nal Ia licensedctio 7000) fto the pro of the Y
of the ss an Profstens Law)or that h is ex encinp with Section 7000)of for the 3 of the ❑
Business and violation of Code)or that nal Ia exempt therefrom and the basis for the alregwtl ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to ANSrU
e civil penalty of not more than live hundred dollars($300).1: MA
Y45 as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES MAY
the work,and the structure Is not Intended or offered for ease(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 CIIY Utrn ura...irx�
Improves thereon,and who does such work himself or through his own employees,provided that LJ
such Improvements are not Intended or offered for sale.If,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) - F-1not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Coda: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 aconiexempt
licensed pursuant to the Contractor's License Lew, PROVIDE MFGR.INSTALLATION SPECS.
❑I em exemptt under Sec. ,B a P.C./or 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:
❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, '7 Building 2�
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this / 9 g,
permit Is Issued. �-w` /'�`�V
El have and will maintain Worker's Compensation Insurance,as required by Section 3700 of J / �� Seismic a aro
the Labor Cotle,for the performance of the work for which this permit is issued.My Worker's
Compensation Insurance carrier and Policy number are: Total 122, f�V
Carrier S/T37�c C4.w.� Policy No. offs--97 —0co, PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.] ti
(Thee section need not be completed if the permit Is for one hundred dollen(5 100)or leu.) _ J(Je K/7 CG t /c•—�v
I certify that in the performance of the work for which this permit is Issued,I shall not employ �J o
any person in any manner so as to become subject to the Workers ensatlon Laws of call- All roofs shall be inspected prior to any roofing material being
f°`nI°. installed. If a roof is installed without first obtaining an
DareTI E TO APPLICANT:
Applicant making
�� inspection,I agree to remove all new materials for inspection.
NOTICE a APPLICANT: II,akar making Ihla ere Lab of Exemption,ya toultl become Applicant understands and will Comply with all non point
withssubject to the Workers'
ions or Compensation l be deem d the Labor Catla,you lorihwlhh comply PP• p y p
with such provisions or this permit shall be deemed revoked. SOUfCe regulations.
I certify that I have read this application and state that the above inlormatlan to correct.l agree
10 Comply with all city and county onlnances 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.
(We)
(We)acne to save,indemnity and keep hay way the Clry of Cupertino against liabilities,
judgments,costa and expenses which may In any way accrue against said City In consequence T DATE 1
of the granting of this permit. SIG URE OF APPLICAN1
PRE-INSPECTION: PLYWOOD: IN-PROGR S:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY