R 5989G
.r-
ERMIT
NUMB R R— 5989
APPLICATION FOR CITY OF CUPERTINO
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WI180
DAYS FROM LA ST CALLED INSPECTION.
BUILDING ADDRESS
,RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
MJ �_
VES ❑ if yes - I understand that a Glass A
NAME /C -P J P1 1'(
root assembly is required.
JJ �NO
ADDREss � �� S �l r �� �2 00-h—_1
❑ Initial I.C.B.O. k
EXISTING ROOF COVERING
PHONE .-✓
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME fyl(� yp 4
ADDRESS— Ot / t70
TYPE OF ROOF COVERING
CITYBZIP— oCl9
EXISTING
PHONE7-V 2 7
BUILT-UP ROOFL ❑
CEN z(�j73
I�3
NUMBER a
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby all that I am licensed under provisions of Chapter 9 (commencing with Section
WOOD SHAKES ❑
7000) of Division 3 of the Business and Professions Code, and my license Is In full force and
effect.r_Z' 7� T
WOOD SHINGLES ❑
LicenseQClaes � Lic. Numb r v
OTHER (SPECIFY) El
Data contra
OWNER.BUIL ERECLARATION r
I hereby aflum that 1 am exempt from the Contractor's License Law for the following reason.
PROPOSED
(Sec. 7031.5, Business and Professions Code: 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 ❑
applicant for such permit to file a signed statement that he Is Ilcensed pursuant to the provisions
of the Contractors 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
ASPHALTr.PIAN GEES [_�
exemption. Any violation of Section 7031.5 by any aPPIKant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars ($500).):
❑l, as owner of the property, or my employees with wages as their sole compensation, will do
work, and the is Intended
WOOD SHA
n E]the
p$'SrD
structure not 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
II,1
sJ
Improve$ thereon, and who does such work himself or through his own employees, provided that
,EE
W00 N LES/�'�
❑
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
u
OTQtA(SPECIFY), I vV
Cl
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.O. REPORT NO.
apply to an owner of property who builds or improves thereon, and who contracts for such projects
with a conlfactor(e) licensed pursuant to the Contractor's License Law.
1 am exempt under Sac. ,B & P, C. for this reason
PROVIDE MFGR. INSTALLATION SPEC$.
Owner Data
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE VALUATION PERMIT FEE
I hereby aairm under penalty of perjury one of the following declaration:
❑ 1 have and will maintain a Certificate of Consent to self -Insure for Workers Compensation,
, J
/
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit is Issued,
.xV Building .
,
❑ have and will Worker's Compensation Insurance, by Seaton 3700
x-,
- $eISmIC
as required 'of
themaintainrt
the Labor Code, for the performance of the work lora which this permit Is Issued. My Worker's
the workfor s
Compansa lin Insurance carrier e�]nd Po cy number arej/Jsyy
// )
Total / 7�
�,No. 7
carded -U j11 /.��'jJ`j�l�1 // Policy /,375
PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p
(This section need not be completed It the permit Is for one hundred dollars ($100) or leas.)
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 Call-
All roofs shall be inspected prlor to any roofing material eing
fornla.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
NOTsubject 2the WE TO orker es' Compensetlon provANT. It, after isionls of tthtelcate of Laborr Code, Exemption,
oiu mustfforthwou lithbecome
comply
Applicant Understands and WIII Comply With all non point
with such provisions or this permit shalGbe doomed revoked
Source regulations.
I certify that I have read this application and state that the above Information Is correct. I agree
Ill fcoverings
to comply with all city and county oMinences and slate laws releling to building construction, antl
hereby authorize representatives of this city to enter upon the above-manflonod property lora In-
to be class R4"Of atter.
..VV
apectlan purposes.`��
(We) agree to save, indemnity and keep harmless the City of Cupertino against Ilabllitles,
.,
judgments, coats and expenses which may In any way accrue against said City in consequence
of the granting of this permit,
SI TORE OF APPLICA T 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