R-5474 PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5474
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (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 n �/�
Z PL14C V y hh
I RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
HOCTOR YES If yes-I understand that a Class A
NAME roof assembly is required.
NO Initial I.C.B.O.q
ADDRESS SA PA E PO hPWt EXISTING ROOF COVERING
PHONE .S 7 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME S 1 /^ NTTU Q�:.
TO BE REMOVED TO BE RETAINED
ADDRESS (() p q TYPE OF ROOF COVERING
CITY&ZIP '1�` AA I Il M EXISTING
800PHONE w0 - L 4-4---7 4- 1 a BUILT-UP ROOFLICENSE
❑ ��j
NUMBER `Q ASPHALT SHINGLES ❑ .
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES �j
7000)of Dlvlalon 3 of the Buslnaee and Professions Code,and my license Is In full force and
effect.
�/✓�� �,f1r_�6 @ WOOD SHINGLES ❑
License Claes�L�J 1— LIC.Number Q* U
Det. I fl-2�I Contractor SIGIJR'rQK C_+ OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
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,after,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 licensed 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 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(S500).): WOOD SHAKES
C]1,as owner of the property,or my employees with wages as their sole compensation,will do 4':❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles-
slons Code: The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLE�C,' q ❑
Improves thereon,and who does such work himself or through his own employees,provided that 16 O
such improvements are not Intended or offered for sale.It,however,the building or improvement J (`n�
Is a Id within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) `1�
not build or Improve for purpose of sale.). Vt
❑I,as owner of the property,em 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:y
apply to an owner of property who builds or Improves thereon,and who Contracts for such projects
with a contrector(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
hereby and ill under penalty of perjury one of the following duce for Wo n
❑ have and will maintain a of the Lab of Consent to self-Insure for Worker's Compensation, I
�� LU( f^ Buildingea provided for by Section 3700 of The Labor Cotle,for the pedormence of the work for which this Vpermit is issued. Seismic O
❑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 Issued,My Workers
CompsnsafoSeand
Policy
numbTotal
/3 4
Carrier }� )P
Policy No. • 1010 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed if the permit Is for one hundred dollars($100)or less.) .-•+! rI1 b '
I certify that In the performance of the work for which this permit Is Issued.I shall not employ l V
any person in any manner so as to become subject to the Workers'Compensation Laws 0f C All roofs shall be inspected prior to any roofing material being
fornix. �s installed. If a roof is installed without first obtaining an
Date 1 D-2-� Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Eire n,you should baa me Applicant understands and will comply
subject to the Workers'Compensation provisions of the Labor Code,you rthwuh ply pP ply 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 state that the above Information Is correctI agree
to comply with all city and county ordlnances and state laws relating to building construction,and All I coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes. jo
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities, i/
judgments,costa and expenses which may In any way accrue against said City in consequence SIG ATURE O PLICANT DTE
• of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IWPRO
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