R 5115 PERMIT q_ 5115
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
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
21447 V 2�� CJ RESIDENTIAL COMMERCIAL OTHER
OWNER'S f HAZARDOUS FIRE AREA
M ft ��Q u YES ❑ If yes—1 understand that a Class A
NAME r N ��""11 roof assembly is required.
NO ❑ Initial I.C.B.O.r
ADDRESS 21h"q'� K4Z-)GN PL. CuFx-dTlao �� /ERING
• PHONE 13 NUMBER OF EXISTING COVERINGS _ LAY
64,
CONTRACTOR'S '
If�C+ Cd //VG TO BE REMOVED TO BE RETAINED
NAME Jd-NA155A�
AooREss ��Z L-IW-6oi mg-4 L75f j TYPE OF ROOF COVERING
CITY&ZIP-. L
PHONE 44qBUILT-UP ROOF ❑
LICENSE
NUMBER �3G ASPHALT SHINGLES ❑
' LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 6(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is In lull tame and
erect. 1/ WOOD SHINGLES
License Cleea`�' Llc.Number 551_ 3a
Date ����- 6 contractor P-E�A tSAW-Gr JZWF-1r4 o OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Lew 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 C1applicant for Such permit to file a signed statement that he Is licensed pursuant to the provisions
• of the ss and tProf License Lew(Chapter a Is ex enclnp with Section 7000)of for ionthe 3 aof the
lleged
ASPHALT SHINGLES ❑
of the Co and orolesel n e Code)or that he le exempt therefrom and the basis for the aIle ee
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars 1$500),):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractoea 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 2A10
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO. LWN -
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractons)licensed pursuant to the Contractors License Law. PROVIDE MFGR. INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason
OwnerDate
WORKERS COMPENSATION DECLARATION APPLICATION DATE VALUATION PER IT4FEEI hereby affirm untler penalty of perjury one of the following declaration:
❑1 have antl will maintain a Certificate of Consent to sell-Insure for Workers Compensation,
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this .�
p m t is Issued.
have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Seismic
_th Labor Code,for the performance of the work for which this permit Is Issued.My Workerb
Compensation Insurance carrier and Policy number are: Total
t ri' f po Policyzq 5_16 PERMIT AUTHORIZA ION DATE 1
Cerner FROM No.
CERTIFICATE EN EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ (�
" (This section need not be completed If the permit Is for one hundred dollars($100)or lase.) SEP
I certify that In the performance of the work for w h this permit Is Issued,1 shall not employ
any person In any mannered as to become sublact me wp re'c mpe on Laws of Call- ; , All too shall a Inspected prior o a oofing material being
fornla. r'Z / ) i�stalled"l(,a,;roof is installed without first obtaining an
Date� Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shallibe deemed revoked. soursregulations.
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 state laws relating to building construction,and All Df con
O ri0gS t0 class"C"or better.
hereby authorize representatives of this city to enter upon the above-menflonetl property for In- C`+j
apacifon purposes. ��
(Wel agree to save, Indemnify and keep harmless the City of Cupertino against Ilebllltles, - 6
• ofthe g�n. c of iand nfo pepen es which may In any way accrue against sale City In consequence 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY