R-5096 PERMIT R_ 509
6
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 i1e Oro u
, /
y 4 I 11J'-f//Q/-yf�sTeq RESIDENTIAL COMMERCIAL OTHER
OWNER'S / HAZARDOUS FIRE AREA
NAME Q �r6ce h B II p YES ❑ If yeas asseundembly
i reqand that. Class A
root assembly Is required.
n n NO ❑ InitialLC.B.O.N
ADDRESS 94// — e J-1-V�rS!9 A0J .�Stgc may" EXISTING ROOF COVERING
501 ,1 Z/{'Q S.e. - y 624 / 5115_3 NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOR /+ /n� /� -
f n,S / �l�s f�O,O 1 AI d TO BE REMOVED TO BE RETAINED
NAME i�(l l I
ADDRESSJ['�� - TYPE OF ROOF COVERING
CITY&ZIP `—r�7<. EXISTING
05 6r _'�
aS� 50.37- 4
PHONE - BUILT-UP ROOF 2J�
LICENSE
NUMBER 3 ASPHALT SHINGLES 0 D
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Coda,and my license is in lull force and A r]R'r p �
effect' LI{/9 WOOD SHINGLES /7r[LI18
License Class ��� Lic.Number L [�� ��
OTHER(SPECIFY) CITY (.t�j�urtHflNO
Date DOaV$Ctp!
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm 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 Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of 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 lour a permit subjects the applicant to
e civil penalty of not more than live hundred dollars($500).): WOOD SHAKES C]1,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the Structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
slons Code: The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided that
Such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER (SPECIFY) ❑
not build or Improve for purpose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an Owner of property who builds or improve$thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Law, PROVIDE MFG R. INSTALLATION SPECS.
❑1 em exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
x. WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, BuildingI47
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
1 pet1.Issued. Seismic
have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
th Labor Code,for the performance of the work for which this permit is issued.My Worker's G Total
Compens n ITure a carrier and Policy number are: Y� 'p Ali I
Carrier l/ m POIIcyNO.ld)9•/III,J7SS PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If the permit Is for one hundred dollars($100)or lass.)
I certify that In the performance of the work for which this permit Is issued,I shall not employ
any person In any manner so as to became subject to the Workers'Compensatmn Law$of cash All roofs shall be inspected prior to any roofing material being
fomla. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOT CE TO 11,afterof Exemtion
subject I.the WorkeraCCompensation proivisionis of the11Labor Code,cate you mustuforthwiitthbecome comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. source regulations.
I certify that I have read this application and state that the above information is correct l 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-
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may in any way accrue against said City in consequence
of the 9rof this Permit. SIGNATURE OF APPLICANT DATE
PRE-INSPECTION:
ION: 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