R-5647 PEIR- 5647
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
RESIDENTIAL _COMMERCIAL OTHER
OWNER'S
�o I�/1 1 1 c /� HAZARDOUS FIRE AREA
NAME • 'v^� 'Vll�s4aLn VES ❑ I Basis,
is�Uf ate ClassA
D }/�_ �J Q NO IniiBI I.C.B.O.x
ADDRESS '1 'D" b x '•'1 `�(p sunnu� & G1-Lo87 EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVEcRRyII,NG�`S�-
CONTRACTOR'S 13 d
TO BE REMOVED 70 BE RETAINED _
NAME 1� _ ,^
ADDRESS M ( - ht / �( TYPE OF ROOF COVERING
I ��� a...7.1
EX
CITY&ZIP , ISTING
PHONE— I�T7 ' �L� BUILT-UP ROOF
LICENSE J/NUMBER f ,g�JC3ASPHALT SHINGLES -
❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES > J
7000)of Division 3 of the Business and Professions Code,and my license is in lull force and /
.lG �21 Z-7 WOOD SHINGLES l6 / ❑
License Clas Lic.Number `sp
Data15fi��_Contractor �� 1'1/`1J6i INS OTHER(SPECIFY) !. ]
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt Imm the Contractor's License Lew 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,prior to its issuance,also requires the BUILT-UP ROOF l(/ /611
applicant for such permit to file a Signed statement that he is licensed pursuant to the provisions
. of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Cotle)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑
axe Mellon.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to s',1p'
e civil penalty of not more than five hundred Boners($500).):gaWOOD SHAKES � �Jr.r C 11✓v
❑I,as owner of the property,or to employees with wages(S their sola compensation,will Plains.
the work,and the structure is not intended ores nottl for sale(Sec. er of Business antl wildso
Improves
Coda:The Contractor's License Law di self rthappryto an ghhiso own
property
es,who rovide that WOOD SHINGLES ❑
Improves thereon,and who doessuchwork himself or through his own employees,provided that
such Improvements are not intended or offered for edea.11,ill however,the enbuildingpr or Improvement
nsold tbuild or
prove for purpose
s the ownerbuilderwillhave the burtlenof provingthat hedid 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 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 contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
-11 have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, q 'O Building
as
provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is Issued. SeISfnIC
'41 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of q ^ M
_thpWor Code,for the performance of the work for which this permit Is issued,My Worker's C� g L/ C..(/ Total
compen�sa.t-iyon�Ins(`�]f`Qa�n���e car�rier and Policy number are: ,.1x�
carder ""�)�"'x r Qli IC, Policy No.N1.VL3 '1 1Z�J�Z ITA THORIZATION DATE
CERTIFIC E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE (D^
(This section need not be completed if the permit Is for one hundred dollars($100)100)or less.)
I certify that In the performance of the waror wh' h This permit Is issued, shall not employ
any parson in any manner so as to become s tact 1 the Workera'Compen n Lx a of tau- All roofs shall be inspected prior to any roofing material being
fornixinstalled. If a roof is installed without first obtaining an
Date biAlApplicant inspection,I agree to remove all new materials for inspection.
'NOTICE TO APPLI A T: II,after making this edificat of Exemption,you shouId become 6cant understands and will comply with all non point
subject to the Workers'Compensation provision the Leb r Code,you must lorihwith comply PP P Y P
with such provisions or this permit Shaklee dee a revoke ourc0 regulations.
I certify that l have reed this application antls a that the above information is correct.I agree
to comply with all city and county ordinances and stale laws relating to building construction,and AIIr Verings toVC
s Or etter.
hereby authorize representatives of this city to anter upon the above-mentioned property for In-
spection purposes. ^ ,. �-7
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities, HSC.. /
• judgments,costs and expenses which may in any way accrue against said City In consequence Sl NATO A T DATE
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: U 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