R 5872 APPLICATION FOR CITY OF CUPERTINO
NUMBIER R- 5872
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
/0 4162 /UoeLAle L)o9saiY
/ � RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
M j YES ❑ If yes—I understand that a Class A.
NAME—H` AiL( "� a-/0 fE y rogf assembly is required.
- IL.3z$ NO Initial LC.B.o.k
ADDRESS 13 Gia My P-TLo- woob Ja.. l52L.ANDO EXISTING ROOF COVERING
PHONE N !} Vse— Q.QM # NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
/� (� TO BE REMOVED TO BE RETAINED
NAME IC2NAI.SSA CAS ,, 7 ,;;x C. 'TNC .
ADDRESSTYPE OF R
ZOOF COVERING
CITYazIP -ZA L (--- LxJCOAV
LA) )`
EXISTING
PHONE iio8-�}4 — 0 6g BUILT-UP ROOF ❑ '
CENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES
00)of Division 3 of the Business and Prolessions Code,and my license Is In full force and
eifecl.
WOOD SHINGLES ❑
Liiccennse Claes' 39 Llc.Number S59?3 6 _
De(ey ��/9 g Contractor OTHER(SPECIFY)
OWNER-BUILDEflDECLARATION ED 2y
hereby affirm Ihel am exempt from the ConirecMor'e License Le ort a following res on.
(Sec.7031,5,Business and Professions Cotle: Any city or coun Inch requires a permit to ❑G'p)
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ` aY -
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Law(Chapter g(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 SHINGLESC.-
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).1:
❑L as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the werk,and the structure Is not intended or offered for sale(Sec.7044,Business and Prefes-
sionsCode:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES El
thereon,and who does such work himself or through his own employees,provided that
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 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(See.7044,Business and Profession 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 Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
El am exempt under Sec. ,B&P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to sell-insure for Workers Compensation, / n BUIIdIn
as provided for by Section 3700 of the Labor Code,for the performance of the worklorwhichthis fJ/yR. 5 C`/Y(f�f g Q
Permit i iesued. ? O y
have end w1II maintain Worker's Compensation Insurance,as required by Section 3700 of $eISR11C
7 O
t r Code,for the performance of the work for which this permit Is Issued.My Workers / Total o
ompensation Insurance carrier and Policy number are: 2, O
Carrier—,S7-A712— f"11D Policy NO, 13GICOx PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.E
(This section need not be completed It 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 shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,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 shall be deemed revoked. Source regulations.
I certify that t have read this application and elate that the above information is correct.)agree
to comply with all city and county ordinances and state laws relating to building c muructien,and *GNATURE
coverings b °or-better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
purposes.
(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. OFAPPLICANT"
DTE
PRE-INSPECTION: PLYWOOD: X IN-PROGRESS: - X
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL: x
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY