R-5476 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 5476
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 J a(']1
10183 PC C I O 01 RESIDENTIl COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
V /,� l o C l3/ Lei
VES yes-I untlerstantl that a Class A
NAME Y`^'' 1 �)` root assembly Is regm'ad.
(�p NO t_ Imbal I.C.B.O.11
ADDRESS S� - f�S A8by EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
I ( y� y-�
NAME .�L6 N !"1 1
��-V��enp TO BE REMOVED TO BE RETAINED
ADDRESS Vit v TYPE OF ROOF COVERING
clTvszlP A1 �/ �/�t /, ffrr 1 TIN
PHONE(PnO (,0 -f`'{' �_741 Q BUILT-UP ROOF ❑
CENSE
NUMBER (O ASPHALT SHINGLES- ❑ ��l
LICENSEDdunderCONTRACTORSsof Chapter 9(N
I hereby iaffirmnion that em licensed under provisions of Chapter y(commencing with Section WOOD SHAKES
7000)of Division 3 0l the Business and Professions Code,and my license Is In full lone and
effect. WOOD SHINGLE c �T
License Class Ic_ Uc.Number O(G"' v REC y e•�L
Date ID-79'92 Comraaor Sr(.4A)Ar"V>IER2 OTHER(SPECI ❑
OWNER-BUILDER DECLARATION PROPOSED OCT 2 91997
I hereby affirm that I am exempt from the Contractor's License Lew 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,prior to Its issuance,also requires the BUILT-UP ROOF BY: ❑
applicant for such permit to file a Signed statement that he Is licensed pursuant to the provisions
Of the Contractor's Llcensa Lew(Chapter B(commencing wlih Section 7000)of Division 10 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
acivil penalty of not mora than live hundred dollars($500).):
Dl,as owner of the property or my employees with wages as their sole compensation,will do WOOD SHAKES El
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles.
sions Code:The Contractors 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,providod that
such Improvements are not Intentletl or offered for sale.IL 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.).
D 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.
❑1 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: I(( ( I
D I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, I�1 �� 1 j oo Building
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this 1111 114 O
permit Is issued. Seismic
D 1 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 mIssued.My Worker's Total
Copensatlo Insurance carrier and
lPollicyn ber are ('`�L
Carrier k Policy No. jjit:�D]o PERMIT AUTHORIZATION DATE
CD
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 ^ p
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) O Q�- 7 •-9
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 Cell. All roofs shall be inspected prior to any roofing material being
fornia. ( moi/ installed. If a roof is installed without first obtaining an
Date l h-2 �r 7Applicant inspection,I agree to remove all new materials for inspection.
NOT subject to Eh Worrkera Compefnsation provlalons of thtelcate Labor Codme
e,you n,you should b omply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. Source 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 ro coverings to be class"C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes. Joh:,?
(We)agree to save,Indemnify and keep harmless the City of Cupertino against Ilabllitlea,
judgments,costs and expenses which may In any way accrue against said City In consequence
• of the granting of permit. SIGNA R F A ICANT ATE
PRE-INSPECTION: PLYWOOD: IN-PROG
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