R-5303 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5303
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 18DAYS OF PERMIT ISSUANCE OR
WI F DANS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS �/s�.
Dr6 Sotj orx RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
VA -1� LIq�d YES [:] If yes—IunderstandthataClassA
NAME V7 L roof assembly Is required.
I / NO Initial I.C.B.O.If
ADDRESS Josh 7 -Sog-� U 47 EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S/ ��pp t+
h i � lCOO TI� TO BE REMOVED TO BE RETAINED
NAME ,,,r ,
ADDRESS 33Z /!+��qr /�Je., s,Ti TYPE OF ROOF COVERING
CITY&ZIP
EXISTING -
PHONE 2 99- 76/57 BUILT-UP ROOF ❑
LICENSE 2-11"65-2-
NUMBERASPHALT 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 Code,and my license Is in lull force and
effect. ,
—39 2-1116-Z WOOD SHINGLES
License Class Lia Number /
Date Contractor
OTHER(SPECIFY) J�
OWNER-BUILDER DECLARATION PROPOSED q
1 hereby affirm that I am exempt from the Contractor's License Law for the following reason. G
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,improve,demolish,or repair any structure,priorto 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 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
e civil penalty of not more than five hundred dollars($500).):
❑I,as owner of the property,or my employees with wages as their sets compensation,will do WOOD SHAKES ❑
the werk,and the structure is not intended or offered for sate(Sec.7044,Business and Pmles-
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 sate.If,however,the building or improvement
Is sold within one year of completion,the owner-builder wilt have the burden of proving that he did OTHER(SPECIFY) ❑
not build or improve for purpose of sate.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec,7044,Business and Professions Code:The Contractors 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. R ��MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B P.& C.for this reason 0 4P'
Owner Date A5WT1VNP6fS VALUATION PERMIT FEE
WORKER'S COMPENSATION DECIARATION
j I hereby affirm under penalty of perjury one of the following declaration:
❑ i '^
' I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, I INL Building (�
♦,- as provided for by Section 3700 of the Labor Code,for the performance of the work for which this µ
i permit la Issued. ffy.uj- VVYl
have and will maintain Worker's Compensation Insurance,as required by Section 3700 of / Seismic
,! th9 Labor Code,for the performance of the work for which this permit is issued.My Worker's
Compen(sationInsurance terrier and Policy number are: Total
Carrier/ Z F'""td' PolicyNo.Z18s'700011yi PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ + '
This faction need
the not be Cance of the
if the permit is for one permit
Is i sued,dollaI($100)or lasso \ys1/^yi_�� l+
person
that In theperformanceso as to al the work for which this permit Is issued shell not employ
any person In any manner so as to became subject to the Workers'Compensation Laws of Cell- All roofs shall be inspected prior to any roofing material being
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,after making this Certificate of Exemption,you should become applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply p Y p
with such provisions or this permit shafQbe deemed invoked. 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 lar in.
apatite)purposes.
(We)agree to Sava,expenses
and keep I harmless the City ai Cupertino against liabilities,
judgments,the grts.costs and expenses which may In any way accrue against sold City in consequence
of the granting of this Parma. SIGNATURE 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 ACCESSTO ROOF SHALL BE PROVIDED-FOR INSPECTION
OFFICE COPY