R 5066 PERMIT R_ 5 0 6 6
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
• - WITHIN DAYS PERMIT ISSUANCE OR
7 DANSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
:PL.2 60 RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
��1 I� T� C)" ,/t^ VES ❑ Ifyeas Iunderstandthat. Class
NAME— lJ" Y/ �7 roofs—I un ryisrequired.
N Initial I.C.B.O.#
ADDRESS EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTORS n p
NAME ud Ot.1N I\OQq' .lip• TO BE REMOVED TO BE RETAINED
• ADDRESS � PG� Dr TYPE OF ROOF COVERING
CITY&ZIP `Q7)--C� r 1�G11n c<L� (w
EXISTING
PHONE 556"Z339 BUILT-UP ROOFLICENSE
❑
NUMBER 6( (o ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑(\
7000)of Division 3 of the Business and Professions Cotle,and my license Is in full force and / N/
anent. ( r�Q WOOD SHINGLES ❑
Cleanse ClAeas `-7p,• Llc.Number 54 45 7 n
Data S ��2� J Contractor Q/d /�b+N 6Goe'Q OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I 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
construct,altar.Improve,demolish.or repair any structure,prior to lie issuance,also requires theBUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
. of the Contractors License Lew(Chapter g(commenclnp with Section 7000)of Division 3 of the
ns
Business and ProfessioCotle)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).): Q
C]1,as owner of the property,or my employees with wages as their sale compensation,w]11 do WOOD SHAKES GGg
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
IQ
sionsCode: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.II,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he dm OTHER(SPECIFY) ❑
not bulk!or Improve for purpose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec,7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bulltls or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
abyaffirm under penalty of perlury one of the following declaration: - /-
hive and will maintain a Certificate of Consent to self-Inure for Workers Compensation, a
ap I=for by Section 3700 o1 the Labor Code,for the performance of the work lm BUII
which this q�� ��
permit is Issued, /2 /,�rr1� seismic
E7J„p°ve
and will maintain Worker's Compensation Insurance,as required by Section 3700 0l ( V V
the or Cotle,for the performance of the work for which this permit Is Issued.My Worker's C� 1996 Total
Compensation 1�bureInce terrier end Policy number are: f fJr.
Carder IAI;Irci Xcil I Po1lcyNo.JkNL 34D9/14-o) �PERMIT
AUTHORIZATION DATE
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE No,[] �7
This section need not be completed 11 the permit Is for one hundred dollars($100)or leas.) 17
certify that In the performance of the work for which this permit Is Issued,I shall not empioy
any person In any manner so as to become subject to the Workers'Compensation Laws of Cml- All roofs Snell b inspected prior to any r offing material being
forma. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subject to the WoCE TO Pkers'Compenaeion proviafter sions ten Labor Code peon,must shame became Applicant understands and will Comply with all non point
you moat lorthwlth comply p y
with such provisions
have
or this permit eha11 application deemed revoked. SOUfCe reg UlatIODS. -
cmtly that1have read Ihietyordinances
state that the above Information incorrect. agree
to hereby comply with all cityrep and county of this costo enter upon he tIngabove-mentioned
to e-mentingon construction,and All root coverings to be class"C"or better.
hereby authorize a rapraeentativaeaf this city to anter upon the ebove•mentlone0 property kr Ispection nt ///1
(We)agree s save,expenses
and keep harmless the City a against
Cupertino aggelnet habitee e,
' lutlgmente.coats end expenses which may In any way accrue epalnet aeltl City In consequence
of the granting of this permit. SIGNATURE OF APPLICAINIT DATE
PRE-INSPECTION: PLYWOOD: r 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