R 5123 PERMIT R_ 5123
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
P. 1 I —IS L&u2_E-rrA RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
(� YES ❑ If yes—I understand that a Class A
NAME 7 /-4 y N roof assembly is required.
NO ❑ Initial I.C.B.O.a
ADDRESSZI I-IS L_AueG7-A Dom' EXISTING ROOF COVERING
PHONE 25 3-2-f-44 NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S
iJ�f_ . AI`�� � TO BE REMOVED ��S TO BE RETAINED
NAME �- ,1
ADDRESSn/� / TYPE OF ROOF COVERING
CITY&ZIP ZZz CII.�iYT�B-�r7 �-ti1.fL
Q EXISTING
S-+—��� BUILT-UP ROOF
PHONE ❑
LICENSE SS� 3
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect.
WOOD SHINGLES (�/
License CI Li
es a Numb
2(o OTHER(SPECIFY)
Date comrad
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 Coda: 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 ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provlslcns
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the /
• Business end Proleeslone Cotle 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 live hundred dollars($500).):
I]1.as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure is not Intended or offered for sale(Sec.7044.Business and Pmfes-
aloneCode:The Contractor's License Lew does not apply to an owner of property who bulldsor WOOD SHINGLES E]Improve°thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.If,however,the bulltling or Improvement
Is sold within one year of completion,the owcer-builder will have the burden of proving that he did OTHER(SPECIFY) ❑ '
not build or Improve for purpose of sale.).
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O. REPORT NG 2 7 1996
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION$PEO$.
El am exempt under Sec, ,B&P.C.for this reason
JIII k/1, L,.ru k1VV
Owner Dere
WORKER'S COMPENSATION DECUBATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: �/
C]1 have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, BUIIdm /
a°provided for by Section 3700 o1 the Labor Coda,for the performance of the work for which this ` �O
permit is Issued. 19 VJ
E]I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of 81�I,0 Seismic
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's /37, q O
.the
Insurance carrier and Policy number are: Total
Carrier �L' eAJ� Policy No. Z$s- 9 L P ITAUTHORIZATI DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE IN C.0 � Q� /1
(This section need not be completed If the permit Is for one hundred dollars(5100)or less.) 'iOKu U q `
1 certify that In the performance of the work for which this permit is Issued,Ishell nom em joy
any person in any manner so as to become subject to the Workers'Compensation Lews of all- All roofs shall be inspects prior to any roofing material being
forms. - installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subject
NOTICE
the TO APPLICANT:
mpel,after n°anon provisions ofthis ethemcate of Labor Code,Exemption,
must forthwithcecome
omplyApplicant understands and will comply with all non point
wlth such provisions or thle permit shaigbe 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 be class°C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In. /��e
spectlon r (`x.'1� COI
(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
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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