R-5587 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 5587
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 br .K; d
oe+- L Pia RESIDENTIAL COMMERCIAL OTHER
OWNER rp)r (.[. HAZARDOUS FIRE AREA
NAME FQC�1 f lQ2Q r /O� VES ❑ If stand is required. Claw
roof assembly is required.
NO Inigal LC.B.O.k
EXISTING ROOF COVERING
ADDRESS -�IB'�S AA�JAt'�` 47�U ?K�JPMS G�� �/I
U _ / NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTORS C
NAMESIU l1fr--,,�1� 'F /74`C f tl454�.� TO BE REMOVED TO BE RETAINED
ADDRESS /t TYPE OF ROOF COVERING
CITY&ZIPL'CiAQSDW - 5 /SII
TI
PHON 7 BUILT-UP ROOF
LICENSE
NUMBER 7xASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that em licensed under provisions of Chapter 9(commencing Sec nWOOD SHAKES 117000)of Division 3 of the Business and Professions Code,and my license Is In fu or and
effect.
_ WOOD SHINGLES ❑
License Cles — �� Lia Number
17=3 -c OTHER(SPECIFY) ❑
Date Cant
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law 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
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
' of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Bi 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
e civil penalty of not more than five hundred dollars($500).1: WOOD SHAKES
E]1,as owner of the property,or my employees with wages as their sole compensation,.111 do ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes.
sions Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-bulder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects RW
with a contractor($)licensed pursuant to the Contractor's License Lew. PROVIDE MF® IN$TAIbON SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Dale APPLICATIO "GATE TION PERMIT FEE
go
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: /S
❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, t Building
as provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this ti
permit is Issued. ///'''��� 146.( Seismic
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of /O-Z� ^1 L y �f�I�I
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's 41 y1 (,
Compensation Insurance carrier an Pohcy nun'Q�err�ere: Total
Carriel.�L♦,•1r� f� Policy No.�,Jl/ter PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION the ON INSURANCE N.C.p t
(This section need not be completed It the permit IS for one hundred dollars($100)or les$)
I certify that in the performance of the work for which this permit Is Issued,I in I'l not employ
any person In any manner so as to become subject to the Workers'Coni Lawa of Cell- All ro,f.^.shall a inspected prior to any roofing material being
fornix' installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subject 1.the Workers'CompeTO APPLICANT: f.after nsation provisions of thelcate of Laborr Code,Exemption,
must forthwith ld comply Applicant understan will comply with all non point
with such provisions or this permit ahambe 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 all city and county ordinances and state laws rotating to building construction,and 11 3 COV rings to class" 'or be er.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
• of the granting of this permit.costs and ae which may In any way accrue against said City In consequence ATURE OF%GhVA NT 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