R 5947 y PERMIT R_ 5947
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
/}p # g 777 3228 PERMIT EXPIRES IF WORK IS NOT STARTED
770 / WITHIN IBR DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS -
az'Q &ezle6-If RESIDENTIAL—&COMMERCIAL OTHER
OWNERS
///1/� L,T/ HAZARDOUS FIRE AREA
NAME IN �// O�L./liL�l�/"/ SES ❑ If yeas I assembly
isreq that a Class A.
��� of yes—
I understand
ty required.
n L / NO Initial I.C.B.O.a
ADDRESS 9� / /U/C`'S/TI/ LGEXISTING ROOF COVERING
(O
PHONE — NUMBE OF EXISTING COVERINGS
CONTRACTOR'S �
S G Q daT/� TO BE REM OVED_TO BE RETAINED
NAME
ADDRESS Po .O h O f TYPE OF ROOF COVERING
CITYaZIa
�?S037 EXISTING
PHONE _ BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALTSHINGLES ❑ /
tic need CONTRACTORS DECLARATION
I hereby sham that I Iq licensed and
Pr provisions of Chapter 0(commencing calif Section WOOD SHAKES
7000)of Division 3 of ih Business entl Proleesiona Code,entl my license is in lull force entl
affect 39 (�/ WOOD SHINGLES /1110
❑
License Class Lic.Number
DataContractor OTHER(SPECIFY) ` /r ❑
OWNER BUILDER DECLARATION PROPOSED
hereby affirmBu that am exempt from the e: Any
or colla Lew for the following reason.
(Sec,7031.5,Business and demolish,
or rep Coda: Any city or county which requires e permit to
construcapplicant for
Improve,to file signed staair tny ement
thate,prior loIts issuance rsuani also requires the BUILT-UP ROOF
applicant for such permit a tint a signed statement that he lith Sectio pursuant to the provisionsothe
• of sin ssContractor.andProfession.
fLicense Lew(Chapter h(commencing with Section 1000)of for the 3 of the
Business end Prolotion of Code)or that he Is exempt antfora and the basis for the applicant
to ASPHALT SHINGLES Y
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of net more than flue hundred dollars($500).);
E]1,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.
alone 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 awn employees,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(.C.B.O.REPORT NO,
apply to an owner of property who builds or improves thereon,and who contracts for such projects !4
with a contractor(s)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR. INSTALLATION SPECS.
C]I em exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PE E
WORKER'S COMPENSATION DECLARATION �
I hereby affirm under penalty of perjury one of the following declaration:
C]I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, PAID
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is Issued. S( iC
❑I have and will maintain Worker's Compensation Insurance,as required by Setllon 3700 0l
,the Labor Code,for the performance of the work for which this permit Is issued.My Worker's
Compensalf Insurance carrier andel cy er1re! Total
Carrier
�x/(( ��'/�/ .y No, UrpfiBMll{ ORIZATIO DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the permit is for one hundred dollars($100)or lase.)
I certify that In the performance of the work for which this permit Is Issued,1 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
ferule. 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: 11,after making this Certificate of Exemption,you should become Applicant subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pp ant understands and will comply with all non point
with such provisions or this permit shal¢be deemed revoked. Source 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 elate laws relating to building construction,and All roof Cover aO be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In. /
sp'W" purposes. �Ll� C�
(Wa agree to save,indemnity and keep harmless the City a of Cupertino against liabilities, tt. ../S'—y
judgments,coats and expenses winch may In any way accrue against saltl City In consequence
of me granting of mix permit. SIGNATURE OF AFFMCAW DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHAAPPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
_.. _
OFFICE COPY