R 5951 APPLICATION.FOR CITY OF CUPERTINO NUMBER R- 5951
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT -#2(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS180 DAYS FROM LAST CALLED INSPECTION.
'
RESIDENTIAL COMMERCIAL OTHER—
OWNER'S
THER
OWNER'''SS/� HAZARDOUS FIRE AREA
NAME 1 .O_ In M O n $ 6 -It' C �( 42(2/"'f"/n 0 ^�G YES ❑ hoof assembly s requiredes-I understand that
Class A
1— NO ❑ Initial I.C.B.O.N
ADDRESS 2& 5 jQ? EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'
NAME
LOS (31CC O 6 �/h TO BE REMOVED I TO BE RETAINED
ADDRESS Los 6--As, 47-S / TYPE OF ROOF COVERING
CIN&ZIP, 1 • dk / t,a L7J
• EXISTING
PHONES o �pZ�Y / BUILT-UP ROOF ❑
NUMBER �7J �}O ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 0(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is In full force and
effect. �`
license Class� Llc.Number $yE ?�/
Y� WOOD SHINGLES ❑
Date contractor OTHER(SPECIFY)
OWNER-BUILDER DECLARATION �✓�
I hereby affirm that I am exempt from the Contractors or county
Law wforhich
re following mason. PROPOSED ^�
(Sac.construct,
It ,improve and Profedemolish,
r rep Code: Any city or county which requires a permit to 7
applicnt,alter,Improve,demelia signed auteny mentrthat he prior tolls Issuance,alsoregovisiins BUILT-UP ROOF ❑
of the
for such permit a ille a signed r 9(commencing
that g it licensedSection
pursuant to the provisions
. of the ss and Pre License Law(Chapter h(commencing with Section 7000)of Division 3 le the p
Business and violation of Code)or thet he is y applicant
therefrom and the heels for the alleged ASPHALT SHINGLES W
exemption pen.Any violation of Section hundred
by any applicant for a permit subjects the applicant m
a civil penalty of not more than flue huntlretl tlollera($500).):
F]1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES �UU� ��SU
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Protea-
sloes 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 Ct I'y Ur v
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 Contractors License Law dose 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 . if
with amexlicensed pursuant to the Contractor's License Lew.
❑I em exemptmpt under Sec. ,B 8 P.C.for this reason Q
PROVIDE MFGR.INSTALLATION SPECS. —
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 Workers Compensation,
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Building/S7,
perEl I mit Is Issued.and - _ -[]p �� Seismic
have end will the performance
Workers f the work
for which ce,this as permit is I by Section Worker's's _I 6
' „the Labor Code,for the performance of the work Ior which Isle permit is Issued.My Worker'6 Total /i7_1
� r Q
Compensatlo nsuronce carrler and Pall nur¢9b'ery§'re: ✓� ^ (((
Carrier 141czW1 M/-//,+aollc N _% ���i-�✓�
v a., PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If the permit is for one hundred dollars($100)or less.) J Qt= A _ I •0. - Z'-1$
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'Compensation Laws of Call- All roofs shall be inspected prior to any roofing material being
fornix. _ installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If.atter making this Certificate of Exemption,you should become Applicant understands and will comply subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP ply with all non point
with such provisions or this permit shalfbe deemed revoked. source regulations.
I certify that I have road 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 cove sto beclass 110. better.
hereby authorize representatives of this city to enter upon the above-mentioned property for Inor
-
spection purposes. �� �
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, �s /r�lillrlsr' 6�JIG
judgments,costa and
expenses which may In any way accrue against said City In coneepuence
. of the granting of this permit. SIG URE 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
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