R-5475 APPLICATION FOR CITY OF CUPERTINO
NUMBERRPERMIT 5475 ,
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (406)777-9228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1B DAYS OF PERMIT ISSUANCE OR
-• 180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
02 PE t RESIDENTIAL COMMERCIAL OTHER
OWNER'ST,A/' HAZARDOUS FIRE AREA
YES yes-I U�+/!�� Ci rL nderstand that a Class A
NAME
roof assembly Is required.
� /� !� NO [ Initial I.C.B.O.#
ADDRESS I O-70 2- rt58`hJL, h, CU MPO JQi(4 EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME J�,Ll/�/#`�� Cff ��V� TO BE REMOVED TO BE RETAINED
ADDRESS t�,y O (eQ �� �,y V .nl „va TYPE OF ROOF COVERING
clTv a zIP qL�l`1 /—[� --7/' �f 141II EXISTING
PHONE t e+ 60 ` *✓ / `� ' b BUILT-UPROOF ❑ //
LICENSE p-
NUMBER 46 ASPHALT SHINGLES ❑ /3/
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Cad ,antl my license Is in lull force and
effect ( WOOD SHINGLES ❑
License Cl/a/ss ` -3 41 ^ Lic.Number lQ �'1
Date —1.��(� `'� / Contractor SI6tl- OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
1 hereby affirm that I am exempt from the Contractor's License Law for the following reason. T_
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to C 1c,T��
construct,alter,improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF A4g
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 01 the �,✓
Business and Professions Code)or that he Is exempt therefrom and the baste for the alleged ASPHALT SHINGL S OCT 1997
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to C J
a civil penalty of not more than five hundred dollars($500).):
❑ WOOD.SHAKESl,as owner of the property,or my employees with wages as their sole compensation,will do BY: ❑
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Proas.
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
such Improvements are not intended or offered for sale.ll,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.).
0 I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec. 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 contractorbi licensed pursuant to the Contractor's License Law, PROVIDE MFGR. INSTALLATION SPECS.
1 am exempt under Sec. ,B 8 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: /��p O
❑Ihed andfor
Section
of
cate of brConsent toe elf-insure for Workers Compensation, lO L°tl lOI^^ �D Building/ / /h
as C]I have
for by Section maintain
a of ma Labor Code,for the performance of me work kr which this /^( 11 C L
permit Is Issued. 'Seismic
I]I 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
Insurance carrier a�nid�Po)licy u(mnber are: Total
Carrier STr ` ✓�'l Policy No. s t I 1��)l/7O J PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed if the permit is for one hundred dollars($100)or less.) g-
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 II- All roofs shall be inspected prior to any roofing material being
forms. installed. If a roof is installed without first obtaining an
Dale (o_2-1-T1 Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of t ptip0yeu ahi b ems Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you mustlonpwit amply pP p y p
with such provisions or this permit shaltbe 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 ail city and county ordinances and state taws relating to building construction,and All coverings to be class"C"or ler.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spa(Alon purposes. (� Z9
Wagree s save,Indemnify and keep harmless the City of Cupertino against liabilities, D
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ofthe gran costs and expenses which may in any way accrue against said City In consequence SIGNATU PPLICANT DAT
of granting of this permit.
.' PRE-INSPECTION: PLYWOOD: IN-PROGR
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