R 5141 PERMIT R_ 5141
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 LASTCALLED INSPECTION.
BUILDING ADDRESS /0
q 3y (r RESIDENTIAL '� COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
y� `n VES ❑ If yes-I understand that a Class A
NAME �� / e 12 a' �'/'4 el /V 1#4 Yl i ✓1 roof assembly is required.
NO Initial I.C.B.O.N
ADDRESS A, V N 2— IF EXISTING ROOF COVERING
PHONE L ;' ,7_ NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S
�A C-i CJ A 114214 r L x TO BE REMOVED TO BE RETAINED
NAME �1 c "O [—.
ADDRESS /� // / �y TYPE OF ROOF COVERING
CITY&ZIP �yU�Y) [id [..i ✓✓r 6P /iw6
EXISTING
PHONE 6e 3 —a'-'I 'j-1 BUILT-UP ROOF
LICENSE ❑
NUMBER — �{� ( ASPHALTSHINGLES /
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em 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
WOOD SHINGLES ❑
License Class q Lie.Numbs
Datereb Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATIN PROPOSED
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 sly or county which requires a permit to
canstrucl,altar,Improve,demolish,or repair any structure,pdor to Its Issuance,also requires theUILT-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 8(commenclng with Section 7000)of Division 3 of the
• Business and Professions Code)or that he Is exempt therefrom and the basis for the alleges SPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than live hundred dollars($500).):
❑l,as owner of the property,or my employees with wages as their sole compensation,will do SHAKES
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Protea.
alone Code:The Contractor's License Lew does not apply to an owner of property who builds or WQ NG LES
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
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(Sea.7044,Business and Professions Code:The Contractors 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 contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B a P.C.for this reason
Owner oats
WORKERS COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: r .
❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compensation, BUIIClIn ✓�
as provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this r g
tel
permit Is leaned. - `v 95 Seismic 2.
❑ have and will maintain Worker's Compensation Insurance,as required by d.My 3700's N ��
-the Labor Code,for the performance of the work for which ihla permit la lesuatl.My Worker's
Campen6etlon11nsuranc carrier and Policy n er are: �l i , lcod Total
Carrier �'r�L r+ �i Policy No. ��Q7 3 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O y Q
(This section need not be completed If the permit Is for one hundred dollars($100)or leas.)
I certify that In the performance of the work for which this permit la Issued,I shall not employ
any person In any manner so as to become subject to the Workers'Compensation laws of Cell. All roots shall be inspected prior to any roofing material being
t fornie. �— installed. If a roof is installed without first obtaining an
Deb_CJ_— 6'4 6 Appllcanl i J inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,alter making t Is Certificale of Exemption,you uld become A Ilcant understands and will
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP comply P Y with all non point
with such provisions or this permit shalgbe deemed revoked. source regulations.
I certify that I have reed 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 coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In
•
ep(We)agrpoaee.
(We)agree to save,pe Indemnify w antl keep harmless the City ori Cupertino against Iiabllen e' LTJ/
of the gmt coats and expenses which may In any way accrue against said Clry In consequence
,. of the gren0ng onme permit SIGNATURE 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
OFFICE COPV