R 5753 G6e, (/
APPLICATION FOR CITY OF CUPERTINO NUMB R R- 5753
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IB NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
R1a_EQ" 41 RESIDENTIALAL COMMERCIAL OTHER
OWNER'S �L+ HAZARDOUS FIRE AREA
NAME � N YES ❑ If yeas assembly
Is andreq that a Class A
roof assembly Is required.
NO ❑ Initial I.C.B.O.k
ADDRESS L02P5 SQ\'t\9-C Dgl-L 'Dl EXISTING ROOF COVERING
PHONE Or- `E33 -52°o A 304 NUMBER OF EXISTING COVERINGS dME
CONTRACT
TO BE REMOVED lo TO BE RETAINED
NAME R
TYPE OF ROOF COVERING
CITV 8 ZIP EXISTING
PHONE X79 �33z BUILT-UP ROOF
LICENSE /_ Sf ASPHALT SHINGLES ElR
NUMBEtt
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section O D SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license is in full force ark✓
effect. OOD SHINGLES
License Class �""` 1.0.Number ❑
/�- p` Contractor D c K� ER(SPECIFY) ElDate
OWNER-the Conn DECLA ATTR ON PROPOSED A
hereby affirm that 1 am exempt from the Contractor's License Law for the requires
followingreason. 'V e
(Sec.70315,Business and demolish,
or re Code: Any city or county which requires a permit to
applicant,alter,Improve,tlemela signed
or repair any structure,prior to its issuance,also requires the BUILT-WP RO e ) ❑
applicant for such permit to lila a signatl statement that he is licensed pursuant to the provisions v/ `C +
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the /y_. � VI
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES S
exemption.Any ltyofnit morelhanli live
byany applicant fora Permit subjects the applicant to LL..
e civil penalty owner not more man live hundred yellers(h wage WOOD SHAKES C
❑I,asndthe structure
tore is of i tendedmy or uttered wages as(Sec.their Bole Business
and drill s- )xi ❑
the work,and he structure is not intended ores not for sale(Sea lir of Business and Proles- vYU
imp's Code:The,a Cent actors License Law does not apply to an owner of property who provided
t or WOOD SHINGLES ❑
improves thereon,andwho does such work himself or Through his own employees,provitletl that �T.K
such Improve manta are not intended or owner-builder
for sale. ill however,the enbuildingr or improvement pjL
is sold ntbuld or
prove for purpose
stheowner-bulltlerwill have the burtlen of proving that he did OTHER(SPECIFY)
not build or improve for purpose of sole.).
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 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 Law. PROVIDE MFGR.INSTALLATION SPECS.
I]I am exempt under Sec. ,B 8 P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building 11_b (D
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Seismic
III have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
,the Labor Code,for the performance of the work for which this permit is issued.My Workers Total l
Compense��o��nnnlnsurance terrier and Policy number are:
Carrier �`f'��C' � !!I Policy No.0r,114Q�1' --'Cr7 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEIIIPTION FROM WORKERS'
COMPENSATION INSURANCE N.O❑ '_ r
(This section need not be ante omtl if the permit is for one hundred dollars($100)or lesslo R
certify Thain the performance to the work for which W permit Is issued, shll not employ
any person In any manner so es to become sub�ept m me werkera'cpmpepaatip'Laws of tali- All roofs shall be inspected prior to any roofing material being
fornia. ' ft`X , ) installed. if a roof is installed without first obtaining an
Data Applicant (C¢— inspection,I agree to remove all new materials for inspection.
subjNOTect lCE to theOWorrkerss'Compefnsation provisions Certificate de,yoiu mus fonnwith comply Applicant understands and will comply with all non point
with such provisions or this permit shi deemed revoked. Source regulations.
I certify that 1 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 Ali Too cove IT t0 Class16or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes. / gill
(We)agree to sovo,indemnily and keep harmless the City of Cupo,lloo against liabilities, L, �j
judgments,costs and expenses which may in any way accrue against said City in consequence SIGNATI OF APPLICANT D E
of the granting o1 this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE Z�Z9A INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY