R-5138 PERMIT R_ 513 8
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3'2'28 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
1 e0 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS �/ `J�/
Z("r,� _V,rzZ t G� Pti I RESIDENTIAL ' ` COMMERCIAL OTHER
OWNER'S I �, p HAZARDOUS FIRE AREA
M e_ ��. oa r� L6.-+vN3 YES If yes—I understand that a Class A
NAME I roof assembly is required.
n ` NO ] Initial I.C.B.O.N
ADDRESS U4'"Cal,q, - gK�.�tc-a-t �L' EXISTING ROOF COVERING
PHONE C— p' ' �' •-✓cz) 14 NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S /� ( J TO BE REMOVED27
, 990
BE RETAINED
NAME r60A`5
1RNfi6 QMp
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP 2Z`1-L LINCOLN AV6 , S.:N . C}. 15I� EXISTING
f PHONE 06z) 4+9 -061:7, BUILT-UP ROOF ❑
NUMBER e59 -;73'o 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 Code,and my license Is In full force and
effect. C 3 �SGi3� WOOD SHINGLES ❑
License rrCles9 ` Llc
Date
.Number
Date K_si. contractor Q��AISJgIJC(� �o17R1� 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 x
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
0f the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
• Business and Professions Coda)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).): WOOD SHAKES ❑
❑I,as owner of the properly,or my employees with wages as their sole compensation,will d0
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profes-
sions Code: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 Wilding or Improvement ^' A
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑ ��•'4�
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct �J L
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE LC.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date
WORKERS COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
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 Worker's Compensation, ^ I^1 `5n,`o/ BUlldl
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this P' A I ®
permit Is issued. $e 1
XI have
'and will maintain Worker's Compensation Insurance,as required by Section 3700 Of
the Labor Code,for the performance of the work for which this perrap Is Issued.My Workers 01� A Total
Compensation Insurance carrier antl Policy number
�are
/: ./,3 My/Lll 1J `�
Canker - `A o �~ PoIIcHylNro.V 25 ' �'�L') - PERMI AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' Af
COMPENSATION INSURANCE N.C.O
(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 hlch this permit Is Issued,I shall not employ
any person In any manner s0 as to become Rub to the Wurkere' omp ton Laws Of can- All roofs shall b75 inspected prior to any roofing material being
fornian. � p installed. If a roof is installed without first obtaining an
Date X�4_ Applmanl inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: II,atter making Is 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
with such provisions or this permit shall be doomed revoked. sour 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 cou aheinances and state laws relating to building construction,and All of coverings to bQ�I8S5 rbetter.
hereby authorize repress of thisblty to enter upon the above-mentlOned 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 IGNATURE 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; O�-SHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY --�