R 5733 APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5733
REROOF PERMIT INSPECTION DIVISION - PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN PERMIT ISSUANCE OR
WIT DAYSS FROM
LAST CALLED INSPECTION.
BUILDING ADDRESS
CJ �reX1I�• RESIDENTIAL COMMERCIAL OTHER
OWNERS � HAZARDOUS FIRE AREA
f Y C I YES ❑ II yes—I understand that a Class A
n
NAME f Y G /� NO ❑ roof assembly is required.
ial LC.a.O.k
ADDRESS a'S� GtY•Q.nt��iP -Ion EXISTING ROOF COVERING
PHONE Q 5—cl5i NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
11 TO BE REMOVED TO BE RETAINED
NAME_Q 2L1A?.ZZI—L•�—�_S�..Y(—
ADDRESS^' �.� ' ,^ n,_ \,r•'e/7S I I TYPE OF ROOF COVERING
CIN 8 ZIP
L-�OS�� �Xl�T1d-G
PHONE BUILT-UP ROOF ❑
LICENSE C ^ �
NUMBER ASPHALT SHINGLES Ldp
LICENSED ONTRACTORS 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 farce and
effect. WOOD SHINGLES 01�_
License Cle Lie.Number 3
DateContractor
THER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby allirm that I am exempt from the Contractor's License Law for the following reason,
(Sec.7031.5,Business and Professions Code: Any.clty or county which mauled a permit to
construct,alter,improve,demolish,or repair any structure,prior to its Issuance,also requires the BUILT-UP ROOF ❑
applicant for Such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's license Lew(Chapter 9(commencing with Section 7000)of Division 3 of the lR L'e(O I n t/
• Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES l-.C.. lL A
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to eG
a clvll penaAcOfi I:
lty of not more than five hundred dollar.($500).): <N ❑ fe51
❑I,as owner of the property,or my employees with wages as their sola campensatlon,will do gWOOD$ KES 1
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles- 7- �t, �'c
siopns Code:The Contractor's License Law does not apply to an owner of property who builds or WOQp�fIINGE;E$ ❑
improves thereon.and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale,ll,however,the building or Improvement vxx+
Is sold within one year of completion,the owner-builder wltl have the burden of proving that he did ERJ(SPECIFY) ❑
not build or Improve Ior purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct `p
the Project(Sec.7044,Business and Professions Code:The Contractor's License Law does not P�OVIDE I.C.B.O.REPORT NO. '1
apply to an owner of property who builds or improves thereon,and who contracts for such projects \\
with a connections)licensed pursuant to the Contractor's License Lew, GPROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the fallowing declaration: /
❑1 have and will maintain a Certificate of Consent to self-Inure for Worker's Compensation, BUllding'r
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 7
p rmit sissuetl. /lo'/�� $eISmIC
have antl will maintain Workers Compensation Insurance,as required by Section 3700 of 1 j
ih L or Code,for the performance of the work for which this permit Is Issued.My Workers Total a/O
'Compo don Insurance carrier and Policy numb or are: ��
Carrjer l) •C- Po Icy No. PERMIT�! PERMIT AUTHORIZATION DATE
CERTWICATEOFEXEMPTI FROMWORKERS'
COMPENSATION INSURANCE N.C.❑ ^
(This section need not be completed It the permit Is for one hundred dollars($100)or lose.) 77—
I certify that In the performance of the work for which this permit is Issued,I shall not am lay f
any person in any manner so as to become subject to the Workero'Compeneatlon Laws of Cell- All roofs shall be inspected prior to any roofing material being
fornix. installed. If a roof is installed without first obtaining an
Dote Applicant inspection,I agree to remove all new materials for inspection.
NOTsubject Ito Rhe WorkersTO 'Compel,after nsation previsions of thellcate of Laborr Code,Exemption.
must forthwithcecome
omplyApplicant understands and will comply with all non point
with such provisions or this permit shalQbe deemed revoked, I - 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 stale laws relating to building construction,and All roof coverings to be class PC"Orb Q•er.
hereby authorize representatives of the 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,
judgments,coats and expenses which may In any way accrue against saidAF le 1104
Clty in conequence
' of the granting of this permit. NAT AP L A 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