R-5404 PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5 4 0 4_J
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 TT
S�r—S rJ 1Y ✓l0rf TV RESIDENTIAL_/S_COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
L s T ti C� 2 YES ❑ If yes-I understand that a Class A
NAME roof assembly is required.
NO Initial I.C.B.O.#
ADDRESS Pitt EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS 0 Al"AL
CONTRACTOR'S
G/ZO H2O R OO/e/N G` TO BE REMOVED Otis TO BE RETAINED
NAME
ADDRESSTYPE OF ROOF COVERING
CITY BzIP 1 / 4li• LY�ll/fZ'r�G"7'p /L /r ZoS
-11�-- y�� a EXISTING
PHONE 7YG ' Zi6 Yr BUILT-UP ROOF ❑
LICENSE
NUMBER _?3,?6_7.:r y ASPHALT SHINGLES ❑
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 Cotle,and my license is in lull force and
effect. 1
L/ WOOD SHINGLES /yam / ❑
License Class C� � g Lia Number �1�'�� J !
Dale 91""9� V 7 Contractor OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
1 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 Conlreclors 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 for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).):
❑I,as owner of the property,or my employees with wages as their sole compensation,wl II do WOOD SHAKES El
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes-
StonsCode:The Contractors 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) T7 ��
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 Cade: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.
E]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: /�
❑I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for performance of the work for which this 9 (�/y
permit Is issued. — 1 —` /p, OQ D' Seismic < 0 O
have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
in Labor Code,for the performance of the work for which this permit is issued.My Worker's
Compensation Insurance carrier and Policy number are: t•. Total
T
Carrier r .9T� N
✓ 10 Policy NAP 10 g7-V w.SJ 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 less.)
I certify that in the performance of the work for which this permit is issued,I shall not employ I
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell- All roots shall be inspipciled prior to any roofing material being
fornia' -installed. If a roof I tall�r{pr{t, ut first obtaining an
Data 9 9 Applicant �� .ill inspection,I agree 10 rejrolo I IE, Ilii aterials for inspection.
NOt to TO APPLICANT: If,after making this Certificate of Exemption,you should come A lican[ under�{3rYd5 IU Qm I with all non point
subject to the Workers'Compensation provisions d the Labor Cotle,you must forthwith comply PP re� r(�Ittlu Y
with such provisions or this permit shall be deemed revoked. SOUfCe regulations.
I certify that I have read this application and state that the above information is correct I agree
to comply with all city and county ordinances and slate 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. p,
(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 SIGNATURE OF APPLICANT DATE
• of the granting of this permit.
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 _