R 5883 FNNPUMBERR,ERMIT
APPLICATION FOR CITY OF CUPERTINO 5883
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
190 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS / ,/
7VO0�.. �yi RESIDENTIAL v COMMERCIAL OTHER
OWNERST C _ HAZARDOUS FIRE AREA
U�2 S L VES I❑ If yes—1 understand that a Class A
NAME �.J L I tel,'e �`ti elm/ f assembly is required.
1 // / NO Initial I.C.B.O.4
ADDRESS
Z! / ZS 7Y d !<L,��rC �Y EXISTING ROOF COVERING
C
PHONIC-6S0 ( � ' ! OSV l Z NU BEROF EXISTING COVERINGS `
CONTRACTOR'S / {/.', T
NAME ` � h cX /— �i 60/ /+1 5' (71 �L r L TO BE REMOVED / TO BE RETAINED
ADDRESS N S`7" TYPE OF ROOF COVERING
CITY&ZIP w 1id:x. ✓ "PSW
p n EXISTING
PHONE 641"o8� Z,86- 9/7 O BUILT-UP ROOF ❑
LICENSE NUMBER 21s—,F1
/S c�1 G ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed untler provisions of Chapter 9(commencing with Sect n WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect.
WOOD SHINGLES ❑
License Clara Lic.Number
Dela Contractor
THER(SPECIFY) ❑
OWNER-BUILDER DECLARATION D _
I hereby affirm that I am exempt from the Contractor's License Law for the following reason. P�
(Sec.7031.5,Business and Professions Code: Any city or county which requires d permit to D
,an
struct,alter,improve,demolish,or repair any structure,prior to Ile Issuance,also requires the UI -UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions (p�
o1 the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the p0 rpm a7 - AMU
• Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged
ASPHALT SH ULC$ rUl'J�J ❑
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).): r�7' r
❑l,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHQKES)r UVr'Cn I flys ,Jxrl
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profits. J��'
alone Code:The Contractor's License Law 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,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.).
❑1,as owner of the property,am exclusive contracting with licensed contractors to construct
the project(Sl 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(s)licensed pursuant to the Contractor's License Lew, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner ogre
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 maintain a Certificate of Consent to mil-Insure for Worker's Compensation, BUIIdin
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is leaned. MAR 9 AN
r
❑I have and will melntain Worker's Compensation Insurance,as required by Sectio 37�p0pp�L� e77 - 111YS D �(/� $elSfrllC
the Labor Co for pedormence of the work for which this mit y� _ [/v TOSS
Companee n n e cit cerrler and Policy number � r IVU
cerrler P y o. PERMIT AUTHORIZATI N DAT
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N. .O
(This section need not be completed If the permit Is for one hundred dollars($100C)or lase.) r `
I certify that In the performance of the work for which this permit Is Issued,I Shall not em toy
any person In any manner so as to become subject to the Workers'Compensation Laws of all- All roofs she bo inspected prior to any roofing ma al being
Ionia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for' spect},
NOTICE a APPLICANT: a attar making lhle of the
of Exemption,you should become. Applicant understands and will coral with all fyo
subject to the Workers'Compensation pakingl this
of ihs Labor Code,you must Ishoullth comply PP comply
with such provisions or this permit shall]be deemed revoked. ' Source regulations.
I certify that I have read this epplicallon 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 Bette
hereby authorize representatives of this city to Doter upon the above-mentioned property for In.
hereby
purposes.
(We)agree to leave,Indemnify and keep harmless the City of Cupertino against liabililles, (/
judgments.coats and expenses which may in any way accrue against said City In consequence
• of in granting of this permit, SIGN 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 COPY