R-5433 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5433
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAYS PERMIT ISSUANCE OR
WI DANSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS ///�
8 l l Ki rn S—r-2 e+ RESIDENTIALCOMMERCIAL OTHER
OWNER'S /� /� - HAZARDOUS FIRE AREA
/ ) ihpn1 1 C - C n q a VES ❑ If yes s I assembly
is req that. Class A
NAME lA! L I lV../ C.L.I ICJ Lr`.. 11.of
yes semblyitand that
8I �� e� NO ❑ InitialI.C.B.O.M
ADDRESS EXISTING ROOF COVERING
PHONE O NUMBER OF EXISTING COVERINGS. I
CONTRA OR'S ' ^ ^�
/L—C/.d�.il/—.✓rIJ TO BE REMOVED__ TO BE RETAINED
NAME � r � /� �� n I
sFa �---+ ��� t-�.t.IL1l TYPE OF ROOF COVERING
CITUaz
EXISTING /!a /",;/PHONE aLA ' l "}'O BUILT-UP ROOF �
__7 S
LICENSE �'�
NUMBER �19 a ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
Hereby affirm that I em Business
licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
]000)of Division 3 of the Business end under
provisions
Code,and mycoolicense is In full h Se antl
effect.
WOOD SHINGLES
License Cas Lic.Number)PjQq
Date Contreora OTHER(SP Cj
OWNER-BUILDER DECLARATION
I hereby aPROPOSED QCT 61991
affirm that I am exempt from the Contractor's License Law for the following res
(Sec.7031.5,Business entl 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-UPR F
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 of the
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SH ❑
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($5001): WOOD.SHAKES
❑I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the slrucwre Is not intended or offered for sale(Sec.7044,Business and Profes.
alone Code: The Contractor's License Lew does not apply to an owner of property who builds or WOOD SHINGLES E]Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not intended or offered for sale.II,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.).
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew 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(a)licensed pursuant to the Contractors License Law. PROVIDE MFGR. INSTALLATION SPECS.
❑I em 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:
p 1 have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, Building as provided for by Section 3700 of the Labor Code,for the performance of the work or which this lv �0�47`J� �D
P
m�sissued. SBISRIIC
,RI have end will maintain Worker's Compensation Insurance,hicthis as required Is I by Section 370001 `—,
t Libor Code,for the petor nce of Ih work for which this permit Is Issued.My Workers
Compenr[etlo ur gar r dP i umber ere: I Total
Carder,V\ �C/J Poncy rb� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N C[D x,�l�V
(This section need not be completed If the permit is for one hundred dollars($100)or less.) VF2 p O /b /4- File
I certify that in the petormence 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 Cali. All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subject the CE OWorkeraCC Compensation prroafter lvisionis of theicate of Labor Code,you mustforthwith become
comply Applicant understands and will comply with all non point
with such provisions or this permit shalfbo deemed revoked. Source regulations.
I certify that I have road this application 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 Iroot coverm to be class"C"of better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in. 10 f�
spection purposes. 1 1
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
ofthe gran costs and expenses which may In any way accrue against said Clry in consequence
of the granting of this permit. SIGNATURqPF APPLICANT DAT
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