R-5423 \f^ NUMBER - 5423
APPLICATION FOR CITY OF CUPERTINO
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS
V✓8- (- _Olj Sl RESIDENTIAL
COMMERCIAL OTHER
OWNER'S /�` p /� /1 ,/� HAZARDOUS FIRE AREA
NAME \Lin 1yC ,S" Pats' 1 SES ❑ It yess I assembly
is reqand that. Class A
root assembly i5 required.
GC�i <�f NO Initial— I.C.B.O.q
ADDRESS//�� '� O36 � � 'Al 1e EXISTING ROOF COVERINr�-G^+,
PHONE "'1`��- 2..53 NUMBER OF EXISTING COVERINGS D� v
CONTRACTOR'S `
I2eS0�/\S(1.`^ {7 ,,��� TY)L,
TO BE REMOVED 1�- TO BE RETAINED
NAME V't r YJ l- 4) 1.,,,1
ADDRESS q k 3 N. �ev�aSlvrFf 1 r I•VIQW TYPE OF ROOF COVERING
clTv s zIP EXISTING
t�SU gloq- (a151 q443PHONE BUILT-UP ROOF ❑
LICENSE /]IV/\ ASPHALT SHINGLES 1-1NUMBER "
LICENSED CONTRACTORS DECLARATION /
hereby affirm that I em sin licensed under Professions
lens of Chapter B(commenting with Section WOOD SHAKES ❑ /�
7000)of Division 3 of the Business and Professions Code,and my license Is In lull lone and
License
C 32y1i WOOD SHINGLES [� !`
License Class� Llc.Number :JAO
Data
lD ' 11;5 ' L�-1 Contractor QeS�Xr(1S�k�12 KW>1 OTHER(SPECIFY) ❑
OWNER BUILDER DECLARATION PROPOSED
u
I hereby eHBthat I am exempt fromthe Contractor's License Law for the following reason.
corms.7031.5.Business and Professions
Cotle: Any city or county which requires a permit to
cormstrapplicant
to filedemolish,signed air statement
eny menthatstructure,prior toItspursuantssuance,else theprovirequires the BUILT-UP ROOF ❑
applicant for such permit to flaw a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law(Chapter B(commencing with Section 7000)of Division a of the
exemption.
and violation of Section
or that ala exempt antfora and the bests for the alleged ASPHALT SHINGLES ❑
exemption.Any violation al Sectlon]031.5 by any applicant for a permit subjects the applicant to
a civil penalty a not more than five y dredemployees
yeesdollars(h waged WOOD SHAKES
❑I,as owner ofthe ture Is n tI to employeesred wages as their sola compensation,will s- ❑
the work,and the structure Is not Intended or offered for eels n ow er of Business entl builds
or
Code:The Contractor's License Law dome not apply to an owner of property who builds or WOOD SHINGLES
Improves tenon,and who does n such work himself or through his own employees,Improvement that
such Improvements are not Intended oroffered for sale. ill however,the en building or Improvement
n sold tbuild or
provearourposetof s le.owner-builtlerwill have the burden of proving that he tll0 OTHER(SPECIFY) ❑
not 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 Code: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 deject.
with a contractor(s)licensed pursuant to the Contractors License Law, PROVIDE MFG R. INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECIARATION
I hereby affirm under penalty of perjury one of the following declaration: D /
1 have and will maintain a Certificate of Consent to self-Insure for Worker's CompensatiolH^ 5 (Y.JI`/i1 Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which t ) ✓✓�
permit lsIssued. .S6 Seismic
IR'(heve and will maintain Worker's Compensation Insurance,as required by Section 3,'/ x D `
the Labor Code,for the performance of the work for which this per I Is Is lied.My Wo re�f�; Total
Compensation Insurance carrier and Policy number arm: W J(J�..
Carrier cin FIA`e Policy No. E MIT AUTHORIZATION DTE
CERI OF EXEMPTION FROM WORKERS' D
COMPENSATION INSURANCE N.C.❑
(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 which this permit Is ISul I shall not employ
any person in any manner so as to become Sublil to the workers'Compensation Laws of Cali- All roofs shall be inspected prior to any roofing trial being
fornia. installed. If a'roof is installed without first obtaining an
Data I (� ' Applicant 1 / r inspection,I agree to remove all new materials for inspection.
NOT EOCIf,
lsCertificate
myiuuibecome
subject toeWorrkersC Compensation proviions of the Labor Code, Mstfothwlhcomply Applicant understands and will comply with all non point
with such provisions or this permit selrl be deemed revoked. Source regulations.
I certify that I have read this eppaacallon 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 Allro f coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection
n- % /////��� ►�///I�^'� �,r��� /�/1 /�
sp(We) purposes. [i{X/Y/ lel 1 / z�U W/"" Vv'I�5 7
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities.
judgments,costs and expenses which may in any way accrue against said City In Consequence SIGNATURE 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: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY