R 5464 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER
R- 5464
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 777-3228 PERMIT EXPIRES IF WORKIS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS /�/
/0&115 SO' F6 •/jj/'hi// ���` . RESIDENTIAL COMMERCIAL OTHER
OWNERS/ /p/Ip y� ^ HAZARDOUS FIRE AREA
NAME_SQ(r,A1.r MG II�Q� - YES I�f assembly requireda ClassA
NO ❑ Initial I.C.B.O.d
ADDRESS 10,515 Sr Al wi, EXISTING ROOF
COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTORS
TO BE REMOVE f TO BE RETAINED'
NAME
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
�1�f 9 � EXISTING
qo
PHONE-(�� C �nTS�/SJ . BUILT-UP ROOF ❑
LICENSE '^^ -- ❑
NUMBER (. o ASPHALT SHINGLES �}J(7_7L
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license le In full force and
affect. WOOD SHINGLES ❑ /�/
License Clee Lie.Number
66 d Data Contract
OTHER(SPECIFY) ❑
( OW from th ILDER DECLARATION PROPOSED P A I ®
I hereby affirm Bu that am exempt from the ,: Any
License Lew for following reason.
Sec.construct,
It ,Improve and demoliProfesh,
or re Cod e: Any city or county which requires also a permit to
construct,°Iter,Improve,to file signed
or repairany structure,prior to Its Issuance,alsoeproviithe BUILT-UP ROOF ❑
applicant for such permit a flaw a signed statement that he with
Section
licensed pursuant 00)of to the provisions the
of me ss and Contractor's License Law(Chapter h(commencing with Section 7000)of for the 3 of theBusineV
.
exemption
entl violation
Code)m that he la exempt Therefrom and the baste for the alleged ASPHALT SHINGL t/
exemption.Any violationof Section 7031by any applicant tote permit subjects the applicant t0
a croft penaltyof not more than flue hundred dollars($500).):
❑1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKEf,ITY OF L;UF'EHf5O
the work,and the structure Is not Intended or offered for ease(Sec.7044,Business and Profes. —�
Bions 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 employee°,provided that
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) ❑
not 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 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 Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS,
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Data
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, BUlldln
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this _ g
permit Is issued. (� /^/x�►
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of �/� - `� I I 1�v+`' Seismic
the Labor Code,for the performance of the work for which this permit Is issued.My Worker's
Compensation In umnee terrier and P lacy number era: Total
CarrieV ,��t Policy No. • Z PERMIT AUTHORIZATION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need not be completed If the permit IB for one hundred dollars($100)or lees.)
I conify that In the performance of the work for which this permit Is Issued,I shell not amptoy
any person In any manner so as to become subject to the Workers'Cwmpenaauon Law°01 Cala• All roofs shall be Ins a ted prior to any roofing material being
fames.
installed. If a roof is installed without first obtaining an
Date�' L�L� Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exam n,1 ou should become
subject to rho Workers'Compensation provisions of the Labor Code, ou mu t forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. Source regulations.
Icertify that l have read this application and Rate that the above infor n Is correct.l 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.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, G. OI
judgment°,coats and expenses which may In any way accrue against said City in consequence
of the granting of this permit. SIGNATURE OF APPLIC DATE
PRE-INSPECTION: PLYWOOD: IN-PROGR
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