R 5934 PERMIT. R_ 5934
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.
BUILDINGff��ADDRESQS ,
0 3 ( RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME " �/1/ls VES ❑ Irf000f assembly s1end that req required.
Class A
/03 /U �tir NO 1 Initial I.C.B.O.q
ADDRESS / Y C �� f�/1it� EXISTING ROOF COVERING
PHONE u 7 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S D
NAME L/FORA//La- _C�G!!i[i LpD�/�V�_ TO BE REMOVED__/_TO BE RETAINED
ADDRESS / T•� TYPE OF ROOF COVERING
CITY&ZIP/-3I S• ��/rDL /¢�y� Ste] , 9J72/^7 EXISTING
PHONE ZS</-/Da 7 BUILT-UP ROOF
LICENSE ❑Eloello*�4::r
NUMBER 3 ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
anent. WOOD SHINGLES ❑
License Claes - le-3r7 Uc.Number ��3�3
Date "A✓8 Contrecto��• f1Gsv�i TwF/ OTHER (SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby atlrm that I am 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,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 g(commencing with Section 7000)of DIVisIon 3 or 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 civil penalty of not more than five hundred dollars($500).):
E]1.as owner of the property,or my employees with wages as their sole compensation,will do gpAgD?§HAKES 1 ,,
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOO SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such improvements are not Intended or offered for sale.IL however,the building or Improvement JO
Is sold within one year of completion,the owner-builder will have the burden of proving that he did urDTH ( CIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct /� ��L
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not CI IXUPROkkII:YElliit.6.0.REPORT NO.F W
Oy
apply to an owner of property who build,or improves thereon,and who contracts for such projects
with a comrector(s)licensed pursuant to me Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I 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 following declaration:
❑1 have and will maimaln a Certificate of Consent to self-Insure for Worker,Compensation, BBuilding /
as provided for by Section 3700 of the Labor Coda,for the performance of the work for which this
permit Is issued, ,S �p
-3 S �d� Seismic �f 0
❑I have and will the performance
Worker's Compensation Insurance,as requiredsu Section 3700 of f
the Leber Code,for the performance of the work for which this permit Is issued,My Worker's
'
Compensation Insurance carrier and Policy number are: Total
Carrier s'' / TE FWINOV Policy No.Z373723'9V PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.D i
(This section need not be completed If the permit is for one hundred dollars(S100)or lase.) ( O •� 3��
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'Compensation Laws of Can- All roofs shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
ecome
subjectICE TO o the Workers'C Comp ,after ensation tion p ovisionis of thecate of Labor Code,Exemption,
mustufo thwlltlhbcomply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked, Source regulations.
I certify that 1 have react this application and state that the above information Is correct.I agree
to comply with all city and county ordinances and sate laws relating to building construction,and All roof verings to be cl ass tWOr 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 Ilabillfles,
judgments,coats and expenses which may In any way accrue against said Cay In consequence
of the granting of this permit. SI UR PLICANT DATE7
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