R-5706 PERMIT R_ 5706
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
10160 -Ir RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME0 1?K-1 ti S roof assembly is required.
/�
NO Inillal I.C.B.O.lt
ADDRESS I O a4' 9MAV!4Kt �A-fill EXISTING ROOF COVERING
PHONE �OS _I v — 1 NUMBER OF EXISTING COVERINGS
CONTRA TOR'S
A
NAME ' i6� f1 �� M��� TO BE REMOVED (' TO BE RETAINED
� .lid
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP S7 43[..ibES.Zt.POPfVE G�3NJv�s EXISTING
n^ (�
4s�aa
PHONE CMI-09� -US_24-94 BUILT-UP ROOF ❑
LICENSE
NUMBER 3675fTG ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under lona of Chapter S(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In lull lone and
enact' WOOD SHINGLES ❑
License Class B Uc.Number 38755.6 f ��
Date J1110µJ ContractoA•rA1-r% - rli OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATIONPROPOSED
I hereby affirm that I em exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,improve,demolish,or repair any structure,priorto ltsasuence,also requiresthe BUILT-UP ROOF El
sop
for such permit to file a signed statement that he Is licensed pursuant to the provlslons
of the Contractor's License Law(Chapter 8(commencing with Section 7000)of Division 3 of the
• Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a clvll penalty of not more than five hundred dollars($500).1: WOOD SHAKES ❑
❑1,as owner of the property,or my employees with wages as their sole compensation,will do
the we Ilk.and the structure Is not intended or offered for sets(Sec.7044,Business and Profes-
sions Code:The Contractor'a License Law I not apply to an owner of property who builds or WOOD SHINGLES E)Improves thereon,and who does such work himself or through his own employees,provided that
Such Improvements are not intended Or oHeretl 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 Lew does not PROVIDE I.C.B.O.REPORT NO. �{O}�e CC
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
wIth a contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
F7 am exempt under Sec. ,B&P.C.for this reason
Owner qp •I TON DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Buildin GC?_
as provided for by Section 3700 Of the Labor Code,for the performance of the work for which this /� m
permit Is issued. {/
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of D ' $e1Smic
the Labor Code,for the performance of the work for which this permit Is Issued,My Worker'sci rk . I 3S'�'
Compensation Insurance carrier and Policy number are: UH (rV Total
Carrier Policy No. PERMI*r`AUTHORIZ911ON DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the permit IS for one hundred dollar e($1 )/0,1 ..) L/
I certify that In the performance of the work for which this permit is Issued,I Shell not employ
any person in any manner so as to became Subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Data 1 Applicant M m inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this derfificate of Exemptlon, ou should become A Ilcant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P Y
with such provisions or this permit shell be deemed revoked, source regulations. -
I certify that I have read this application and state that the above information Is correctI 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.
sp(We)agree
los. �.L!!J4.f�C.Y.!'/
(We)agree s save,expenses
and keep harmless the Clry ai Cupertino against liabilities,
judgments,gran angle and expenses which may In any way accrue against said Clry In consequence SIGNATURE APPLICANT
of the granting of this Permit.
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