R 5862 PERMIT R_ 5 8 6 2
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
BUILDING ADDRESS
780 DAYS FROM LAST CALLED INSPECTION.
� (//�
IU5 Gta,em WOOco, RESIDENTIAL COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA
NAME �M, l (IAN, 0i YES ❑ Ryes—Imbly is endued. Class
roof assembly is understand
that
'I _ (� NO ❑ Inroal I.C.B.O.q
ADDRESS 4 l�,-AA.Q I N Iil2a0 EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS /
CONTRACTO `
NAMEL', TO BE REMOVED TO BE RETAINED
ADDRESS Qb TYPE OF ROOF COVERING
CITY a ZIP
Q V' c I
PHONED! f�q `+ I BUILTUPROOF� -
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION � -
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES —C&I 6`
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
affect. (2 9 q WOOD SHINGLES ❑
Llcenae Claes_S�l_ Lic.Number
-/6 -2� Q OTHER (SPECIFY)
Date Contractor r T�❑�'
OWNER-the Conn DECL License
N PROPOSED 4�
hereby affirm that t em exempt from the Contractor's License Lew for the following Ian.
(Sec.7031.5,Business and demolish,
or rep Code: Any city or county which requires a permit to p ry Affil ffil
construct,alter.Improve,to file signed
or d statement
structure,prior to Its Issuance,also requires the BUILT-UP ROOF ATR[ L +'llCil Atl
as
for such permit to Iiia a signedr 9(commencing
nci g it licensed Pursuant to the provisions
the
of the Contractors License Lew(Chapter a(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the basis fon the alleged ASPHALT SHINGLES CITY Qft§Ut h-1,1 G
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to _
e civil penalty of not more than five hundred dollars($500).):
E)1.as owner of the property,or my employees with wages as their sale 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 Lew does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,providod that Elsuch Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is Bold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) [g�M%n/aJiJ Pte'
not build or Improve for purpose of sale,),
❑I,as owner of the property,em 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 contractor(a)licensed pursuant to the Contractor's License Lew.
❑ PROVIDE MFGR.INSTALLATION SPECS.
1 em exempt under Sec. ,B&P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATEI VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: �S
❑I have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, Building
/
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this g
permit Is Issued.
17Mva and will maintain Worker's Compensation Insurance,as required by Section 3700 of I Q Uv Seismic
the Labor Code,for the performance of the work for which this permit le Issued.My Worker's q� `I/q V
Compensation insurance carrier and Policy number are: Total
Carrier r,l 4 1 Policy No./JrW✓777 PERMITAUTHORIZATION DATE
DER nF ATE 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 lees.) (L7
I certify that In the performance of the work for which this permit Is Issued,I Shall not employ
any person In any manner so as to become subject to the Workers'Compeneatlon Laws of Cali. All roofs shall be inspected prior to any roofing teri eing
fornia. installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,offer making this Certificate of Exemption,you should become
subject to the Workers'Compeneatlon pravislone of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. source regulations.
I civilly 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 r better.
hereby authorize representatives of this 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 Ilabllltles,
jutlgmante,coats and expenses which may In any way accrue against 6aitl Clty In consequence DATE
of the grenhng of this permit. SI 'NATURE OF APPLICANT
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY