R 5850 PER
APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 585
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408)777.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
_ WITHIN 180 DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS
180 DAYS FROM LAST CALLED INSPECTI N..,� ( l
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
C ' r `a� VES ❑ Ii yes-I understand that a Class A
NAME L=-R+ 1^c V� roof assembly is required.
NO Initial I.C.B.O.p
ADDRESS (�O�S 11�tS `P �,� EXISTING ROOF COVERING
PHONE \ -1 V -Z .3 NUMBER OF EXISTING COVERINGS
CONTR�TTOR' - t
NAME `�"-'( PSn 4 W t� c L � �lw TO BE REMOVED TO BE RETAINED
ADDRCITY&E2IP `1 -0\\ ) 1�oY. Z1 ! ) �P Rfl �.�W TYPE OF ROOF COVERING
EXISTING
PHONE` � ,J q BUILT-UP UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES
LIC licensed
CONTRACTORS DECLARATION
'thereby affirm That em Business
under Professions
loss of Chapter a(commencing withSectionWOOD SHAKES
7000)of Division 3 of the Business entl Profeeslons Code,and my license is In lull force end
effect. WOOD SHINGLES �[�
License Class Lid.Number— L ,Z r)
Do q—7ContractorOTHER(SPECIFY) 13
OWNER-BUILDER DECLARATION PROPOSED APR 23 ANS'D
1 hereby affirm that I am exempt from the Contractor's License Lew 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 CI t ❑_ .
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter a(commencing with Section 7000)of Division 3 of the -
Business and Professions Code)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).):
01,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 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 did OTHER(SPECIFY) ❑
not build 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 Profoselons 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 contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B 6 P.C.for this reason
OwnerData
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
'
I hereby affirm under penalty of perjury one of the lollowing declaration: ^
❑1 have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, BUl kiln
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Q '\ ^�� Building
.6-1---Is Ive and j7 �( /t � Seismic
❑I have and will maithe performance
Worker's f ina work
for which ce,this as permit is Issued.
Section Worker's's v 1 (T' Q o
the Lebon Code,for the performance of the work for which this permit Is issued.My Worker's I Total I 0
Compere I n IgaurenCe cpr�s��Policy number are: ` ' ^�
Carver Y � Policy No. 3QSZ� 1 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the permit la for o e hunOf dollen($100)or lees.)
I certify that In the performance of the work for whic per Itisued,I Shell not employ
any person In any manner se as to become subject t a or 8. ensalla Law,of Il- All roofs shall be inspected prior to any roofing mattrial g
farms. installed. If a roof is installed without first'.obtaining an
Date�T 15 Appllca inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,alter makin lhlr qq to al Exemption,you should become
subject to the Workers'Compensallon prov a 071.1�9'Lebar Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed r4444eked. source regulations.
I certify that I have road 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 All roof cov It be class"C"Orbe _
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(Wo)agree to save,Indemnity and keep harmless the City of Cupertino a?alnst liabilities,
judgments,costa and expertise which may In any way accrue against said Cityn consequence
citrus granting of this permit. OFA IC NT 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
OFFICE COPY