R-5513 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 5 513
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
3 YY\` 1("� .e�7 Q r � RESIDENTIAL COMMERCIAL OTHER
OWNERS \ HAZARDOUS FIRE AREA
V O S o✓( n ( �wQ VES ❑ "i assern understand required.frieire . Class
NAME ( _�/�, aY is r wired.
NO Initial LC.B.O.M
ADDRESS 7�_ EXISTING ROOF COVERING
PHONE . — NUMBER OF EXISTING COVERINGS v
CONTRACTOR'S /� TO BE RETAINED
NAME � Q..��
/i7_ 1 _S a TO BE REMOVED
ADDRESS^1 /j� AA , _^ n _ TYPE OF ROOF COVERING
CITY a ZIP 1�l� X J�c�(p EXISTING
PHONE !�Jo k •3 S 8• l 2,33 BUILT-UP ROOF ❑
LICENSE
NUMBER ,. I ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em Ilcensetl under provisions of Chapter a(commencing with Section WOOD SHAKES ❑ �O
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
affect. /1 (] WOOD SHINGLES
License Class �- 3 q Lic.Number '`404 6_8 4(00
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec 7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,after,improve,demolish,or repair any structure,pdor 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(Chapter 9(commencing with Section 7000)of Dlvia10n 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 eppliwnt to
a civil penalty of not more than five hundred dollars($500).):
C] WOOD SHAKES I,as owner of the property,or my employees with wages as their sole Compensation,will do ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes. w
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that '•1 r
such improvements are not Intended or offered for sale.It,however,the building or improvement ($
is sold within one year of completion,the owner-builder will have the burden of proving that he did CTHER(SPECIFY) Fps
not build or Improve for purpose of sale.).
❑I,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.0.'RFyPrORT
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.IN$TALI XIQ��$PEC$.
❑1 am exempt under Sac. .B 8 P.C.for this reason 0
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one 01 the following declaration:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, BUIIdin
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is Issued. Seism
[II 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 Worker's
-the
sonnInsurancee�carrier and Policy number are: �� Total
Carse�. )VY-I, 7 Policy NolI A'LIIk 1SS PERMIT AUTHORIZATION DATE
CERTI E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N O.0
(This section need not be completed If the permit Is for one hundred dollars($100)or less.)
I 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 subject to the Workers'Compensation Laws of Cali. All roofs.shalfbMspected prior to y oofing m feria being
fornia. installed. If a roof is installed with Ut first obtaining an
Date Applicant inspection,I agree to remove all new Paterials for inspection.
subs ctt.theWorkers'CompefnsatT CE TO APPLICANT: ornprovmakitisionlsofthelLaborrCode,cate of yoiumustufothwithshould bomply ecome Applicant understands and will comply with all non point
with such provisions or this permit shallibe 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 slate laws relating to building construction,and All roof cov i gs to be class r better
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
Bpection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against inclines, �¢a•G_- 5 / 7
judgments.costs and expenses which may in any way accrue against said City In consequence SIGNATURE OF A LICANT DATE
of the granting of this permit.
f. 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