R 5834 PERMIT R_. 5834
.
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 M J
ID141— 10143 " I E-9—
RESIDENTIAL
COMMERCIAL OTHER
oWNER's HAZARDOUS FIRE AREA
�A R LM Th oM A-S YES ❑ rwf asIf yes—embly i required.a Class A
NAME L /L ' ) I roof assembly is required.
355 164/,q�A ftV& q NO ❑ Initial I.C.B.O.N
ADDRESS /n t 1 1 r `1�1,UI EXISTING ROOF COVERING
PHONE 4W3 0 $422 NUMBER OF EXISTING COVERINGS (WE
CONTRACTOR'S
� 1-/Ss�/'I rs TO BE REMOVED TO BE RETAINED
NAME 1. �Q.[ ,a,1 l_IF�IL G Gn�c
ADDRESS
IDD�SIP�06 ` r rJ ' l r�J I J� '�l I fJ� J�17 TYPE OF ROOF COVERING
. 408 zbz 2 -57 - EXISTING
LICENSE
PHONE 2 BUILT-UP ROOF El
NUMBER 4 �3 ASPHALT SHINGLES
El
LICENSED CONTRACTORS DECLARATION `
hereby affirm that em Ilceneed under fessprovisions of Chanter y license
In with rcecand WOOD SHAKES )�`-'[`
]000)of Division 3 0r'the Business and Professions Code,entl my Ilcenae le In lull force entl � '
alfa°L (n' WOOD SHINGLES El
License Cle `-� 50 Lid.Number -74/Z03
7
Dale : 17 Contractor IC4 1-�$ '/y� ES OTHER(SPECIFY) El
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(See.7031.5,Business and Professions Code: 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 provisions
Of the Contractor's License Lew(CheDter B(commencing with Section 7000)of Division 3 of the
• Business and Professions Code)or that he Is exempt therefrom and the heels for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than live hundred dollars($500).):
E]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 Profes.
sions Code:The Contractor's License Lew 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 bulltling or Improvement
Is sold within one year of completion,the ownerbullder 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 oxclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Lew 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 Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
[II am exempt under Sec. ,B 8 P.C.for this reason
owner Date ATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: z� J
❑I have and will maintain a Certificate of Consent to sell-Insure for Worker's Ccmpensabon, 4 •I 606 BUlldlnf�
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this S— ( O
permt Is Issued. Seismic I have and w1II maintain Worker's Compensation Insurance,as required by Section 370 0
th Labor Code,for the performance of the work for which this permit Is Issued.My W e C}�� O ,/ �r�
CompeneaIIf Incur nce carr1 rand P,/olicy number are: '/n Tota / Q
Carder v��fC UNL(/ Policy No. 4137`x"! AU ZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p ��^ q7-
� ^
(This section need not be completed If the permit Is for one hundred dollars($100)or lees.) K 9
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 eublan to the Workere'Compensation Laws of Cell All r shall nspected prior to any roofing material being
1°`nie. installs f roof is installed without first obtaining an
Data Applicant inspection, gree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,after making this Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shelf be deemed revoked. Source regulations.
I certify that I have reed this application and elate that the above Information Is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction.and Aroof coverings to b class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
eppurposes. f I 9_ /
(We)
(We)agree to save,Indemnify and keep harmless the City of Cupertino agelnel liabilities, \_�-Jf/—�V
judgments,costa and expenses which may In any way accrue against said City In consequence
• of the granting of this permit. ATURE 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY