R 5599 PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMBER " 5 5 9 9
INSPECTION DIVISION PERMIT EXPIRATION
_ REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN See DAYS OF PERMIT ISSUANCE OR
180 WITHIN
FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESUDENTIAII, III COMMERCIAL OTHER
OWNER'S I HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAMEEQ� roof assembly is required.
NO Initial I.C.B.O.(t -
ADDRESS SAMA
PHONE EXISTING ROOF COVERING
` NUMBER OF EXISTING COVERINGS
'
CONTRACTOR'S
^ �"1 TO BE REMOVED TO BE RETAINED
NAME F�I.IIL FQ}�M ren
ADDRESSa (��� °Ya17S PE OF ROOF COVERING
CITY B ZIP !=Anr�o 49,049,09-W7Y\ l• .�.
EXISTING
PHONE__ 21y - \QC 1 BUILT-UP ROOF ❑
LICENSE
NUMBER i ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Cotle,and my license Is In full force and
effect, —I WOOD SHINGLES ❑
License Class 9=1Lic.Number 359g O0 I
Date ��-1--R1 Contractor—QN1L _?WQ6H k:1 OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that am exempt from the Contractor's License Law for the following reason,
(Sec.70375, ,Improve and demolish,
or rep Code: Any city or county which requires a Dermal to
construct ever,Improve,to Ple siorrepairenystructure,prior toue lesuance,also requires the BUILT-UP ROOF ❑
of the
for each permit to flaw a signed statement that he Is licensed pursuant to the provisions
the
of the Contractor's License Lew(Chapter a(commencing with Section 70001 of Division 3 0l the
Business and Professionsviolation
or that he is exempt therefrom and the basis For the applicant
ASPHALT SHINGLES ❑
exemption.Any violation of than
len 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than live 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 Proles-
' slonsCode:TheContracto'sLicenseLawdoesnotapplytoanownerofpropetywhobuildsor 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 -
Issoldwithinoneyearofcomplellon,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(a)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
[II am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT F
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 Code,for the pe rformanco of the work for which this
permit Is Issued' P A I ® t DOE Seismic
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
.the Labor Cotle,for the performance of the work for which this permit Is Issued.My Worker's
Compensation Insurance carrler antl Policy number are: Total
Carrier GOLPSN 1;4_r_— Policy No. RIZATION DTE
CERTIFICATE OF EXEMPTION FROM COMPENSATON INSURANCE WORKERS' NC❑ GL f ull, GUIDE f
(This section need not be completed If the permit Is for one hundred dollars($100)or lees.)
I certify that in the performance of the work for which this permit Is Issuetl,1 shall not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of Ce11- All roofs shall be inspected pficir to any roofing material being
forms. installed. If a roof is installed without first obtaining an
Data 10-Z_CI 1 Applicant I r_ t CA16T inspection,I agree to remove all new materials for inspection.
NOTICE If,
making
itilyou
should
subject to the Workers'Compensation provisions ofheLaborr Code,you mstfothwihcomply Applicant understands and will comply with all non point
with such provisions or this permit shallibe deemed revoked. SOUfCe regulations.
I certify that I have read this appllcatlon 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 I All r of CO ran O be lass"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in. a
spection purposes.
(We)agree to save.Indemnity and keep harmless the City of Cupertino against liabilities, 1 O 2.
judgments,costs and expenses which may In any way accrue against sola City In consequence SIGNATURE OF APPLICANT DATE
of the granting of this permit.
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