R 5577 APPLICATION FOR CITY of cuPERrlrvo
PERMIT 5577
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(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
o p r�Gtk ko ZCAL RESIDENTIAL--&—COMMERCIAL OTHER
OWNER'S `` /n� 1,_ ,A HAZARDOUS FIRE AREA
NAME Pefi � Pk&Z^- A-DA YES ❑ •% =1assemblysrequihata ClassA
C/O assembly required.
Pal
1 I NO Initial I.C.B.O.N
ADDRESS—
PHONE
uC t 1�L S�ZttcS I�ln, t 2$I 0 S�CVCnS EXISTING ROOF COVERING
v Crutc. Iva•
PHONE LI0 4 5 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S -
NAME . '.SCCLAA +- Ai( 545'ell TO BE REMOVED TO BE RETAINED
ADDRESSTT_ _ Q PE OF ROOF COVERING
CITY&ZIP (.9 -7 KST_
I�I( Z
/' EXISTING '
PHONE C y 0B I1 I — 1 ]17 BUILT-UP ROOF �
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is in full force and
eHec6
C-31 4.6-a� 50 r1 D 10 WOOD SHINGLES ❑
License Cleee c.Number '
Date I —31— 98 Contractor .Slrwi laaFi w 3yr 1CWtS OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATID PROPOSED
I hereby affirm that I em 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 Contractors License Law(Chapter g(commencing with Section 7000)of Division 3 of the py
Business antl Po
Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES 1�
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a cJAA ivil penalty o1 not more than five hundred dollars($5001.):
❑1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES JA
s^r}. Q
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes. 27 A fq
slons Code:The Contractors License Law does not apply to an owner of property who builds or � ��UUPPUWJ
Improves thereon,and who does such work himself or through his own employees,providedWOOD SHING
that �
such Improvements are not intended or offered for sale.II,however,the building or Improvement UF
Gut
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) rllfrtgt
not build or Improve for purpose of sale.). LT
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors 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 lar such projects
with a contractor(s)licensed pursuant to the Contractor's License Law, PROVIDE MFGR. INSTALLATION SPECS.
I:I am exempt under Sec. ,B&P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to seil-Insure for Workers Compensation, / �� Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Un O g
permit Is Issued. S j�
❑1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of I�f-, ,
the Labor Code,for the performance of the work for which this permit is issued.My Workers v
,the
Insurance carrier and Policy number are: TDtal
Carrier P��ItL r-hClavr• l"L Pa1foy.No, a 5 Z 1 $�3 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMP ON FROM WORKERS'
COMPENSATION INSURANCE N.C❑
(This section need not be completed If the permit Is for one hundred dollars($100)or less.)
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 roof^shall be ms ted prior to an r-ohng eria e'
fornia. installed. If a roof is installed with Ut first o taining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: 11,after making this Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understan and will comply with all non point
with such provisions or this permit shalObe deemed revoked. SOUfCB regUlatrsta
I certify that l have read this applicatlon and state that the above information is correct.I agree
to comply with all city and county ordinances and state laws relating to building conatruclion,end. OOf Coverings t be lass"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
sp(We)agrpasea. `^ ^� r
(We)agrees and
e,i e smnlly and keep harmless wa the Clry ai Cupertino against liabilities, �/ 1
judgments,coats antl permit. s which may in any way accrue against said City In consequence
of me granting of this permit. GNATURE OF AP (CANT 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