R 5259 PERMIT R_ 5259
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
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS IA-
RESIDENTIAL t/ COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME__ ��-:c�I�'� -roof ass "is required.
NO Initial I.C.B.O.If-
ADDRESS cc EXISTING ROOF COVERING
PHONE \ / �0 Z NUMBER OF EXISTING COVERINGS
CONTRACTOR'S o
✓L`/57, �„k foo a/ /� TO BE REMOVED TO BE RETAINED
__
NAME - 1'
' ADDRESS /0 ry O ��s ?� TYPE OF ROOF COVERING
CITY&ZIP b
EXISTING
PHONE �l
BUILT-UP ROOF ❑
LICENSE
NUMBER / 7� - ASPHALT SHINGLES ❑'
LICENSED CONTRACTORS DECLARATION
thereby affirm that I am licensed under provisions of Chapter 0(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% `/ 45 0;R (SPECIFY)
NGLES ❑
License Class � Lie.Number 7 7^�
Data �O— ZZ—GG Contractor & �0!•y�y OWNER-BUILDER DECLARATION /I hereby affirm that I am exempt from the Contractor's License Law for the lollowing reason(Sec.7031.5,Business antl Professions Cotle: Any city or county which requires a permit to
construct,eller,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUIO ❑
applicant for such permit to fila a signed r 9(commencing
that he Is licensed d pursuant to the provisions
of the Contractor's such License Lew(Chapter a(commencing with eased 7000)of Division 3 of the
Business and Professions Coda)or that he Is exempt therefrom and the heels for the alleged ASP II��jLES
ex ❑
exemptioptio n.Anyviolationo t more
of than
fan 7031.5 by any applicant for a permit subjects the applicant to /
. civil penalty of not more than five y employees
yeesdollars with
wag.):
❑Las and
er the structure
I not i tended oyeeered for
(as Sec.their Bole compensation.sand
Prwill f s. WOOD SHAKE/
the work,antl tee structure is not intended ores not
for sale(Sec.7044,Business end Proles- G�
amore Code:The.a Contractors Licence Lew does s not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,end who does such work himself or through his own employees,Improvement provided that ❑
such Improvements are not intended or offered for bale.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) El
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 Codd: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 contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFG R. INSTALLATION SPECS.
E]I am exempt under Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE1 VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: e
❑I have and will maintain a Cortificata of Consent to self-Insure for Workers Compensation, BUlldln
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this (/'27 f��
parrot ial,ated. 2199 'v 4-4e+ seismic
have and will maintain Workers Compensation Insurance,as required by Section 3700 of /
„t L bor Code,for the performance of the work for which Ihls permit Is issued.My Workar'e
ompensallon Insurance carrier and Policy number are: t't Total
Carrier �' 'e'r 0566x& Policy No. /_$If/7/ fG rM 4TENOIT AUTHORIZATION DATE
�41111116. CERTIFICATE OF EXEMPTION FROM WORKERS' O
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the permit is for one hundred dollars(51 00)or less.)
1 certify that in the performance 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 roots shall be inspeCed 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.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will w' all non point
subject to the Workare'Compensation provisions of the Labor Code,you must forthwith Comply PP comply P
with such provisions or this permit shall),be deemed revoked. Source 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 state laws relating to building construction,and All rO Verl eC "Or com I better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spa tion(We)
purposes. A_ ZZ —fe,
(We)agree s save,indemnity and keep harmless the City of st sold
against liabilities,
jusgmarts,coats and expenses which may In any way accrue against Bold City In consequence
of the granting of this permit. 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
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