R-5297 PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMBER R— 5297
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-:3'228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS t
21 `16jSSN R&tyLo CA-, RESIDENTIAL !!L COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
- �I��A "ll4 y�q YES ❑ It yes—I understand that a Class A
NAME �'� 1 roof assembly is required.
NO Initial I.C.B.O.N
ADDRESS Zl'1SS' �a�y�a-t^ C�'• EXISTING ROOF COVERING
• PHONE -2— NUMBER OF EXISTING COVERINGS '
CONTRACTO/^R'S``�� TO BE REMOVED TO BE RETAINED
NAME Aq S "�.nS � a�ti1`� a IAC-,
ADDRESS 394 R-A Sa'&A- 3aw— 9siLl TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE 9 Z "`fid' - BUILT-UP ROOF ❑
LICENSE
NUMBER PHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing nWOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In lull for
affect
(' 9 WOOD SHINGLES ❑
License Close "'_6� Lic.Numbe�rt������) �Sa /
Data � Contractor �'+"""— N� OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION rPROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,demolish,or repair any structure,prier to its issuance,also requires the BUILT-UP ROOF ❑
appilcant for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 9(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(8500).):
❑l,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 Contractors 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 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.).
❑I,as owner of the property,am 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.
ClI am exempt under Sec. ,B a P.C.for this reason
Owner Date 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
as provided for by Section 3700 of the Labor Coda,for the performance of the work for which this /L 5-6/
permit h issued. DEC _ 61996 I Seismic
have and will the performance
Worker's Compensation Insurance,as required is i by Section 3700's v `7
ih bor Code,for the pedormance of the work for which this permit is Issued.My Workers
CompensationAl urnan_ce.ca-rrieerrandPolicynumberare: ���(i ,f �$%� OWE . .,, Total
Carrier �z+e-x-�s�sv"'� PplicyNn. cq(4`�-3oJ"� I PERMIT AUTHORIZATION DATE
CERTI KATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I] 1^J
(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 shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,she,making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must fodhwlth comply PP P Y P
with such provisions or this permit shaiQbe deemed revoked. SOUfCe regulations.
I certify that I have read this application and stale 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 coverings to lass"C°Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes. }��—�
(We)agree to save,indemnity and keep harmless the City of Cupertino against Ilabllities, �.Diet
judgments,costs and expenses which may In any way accrue against said City in consequence
of the granting of this permit. SI 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY