R 5581 APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5581
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 pry /'► 1'V
19 5 r-Eak PI O-z"', �1L/yK RESIDENTIAL COMMERCIALOTHER
OWNER'S HAZARDOUS FIRE AREA
�T YES ❑ If yes—I understand that a Class A
NAME P Y I GZw Hb� roof assembly Is required.
O G NO Initial I.C.B.O.N
�
ADD R � PGICIT,L S'� -5 M.9WI x�0 VC.CUL �, EXISTING ROOF COVERING
PHONE 08 O V S NUMBER OF EXISTING COVERINGS '
CONTRACTOR'SII �j G /I
NAME CUA I M R 001 ,!2 1 a"of Air ,7 S TO BE REMOVED TO BE RETAINED
ADDRESSTYPE OF ROOF COVERING
CITY a ZIP In77 K4,4 C.,,> SiT 5711 2
r \ EXISTING
PHONE—`L'IOB J �I71 — 1�-�� BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
-' I herebyaffirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑ j�
7000)of of felon 3 of the Business and Professions Code,and my license Is In full force and
effect. qq T WOOD SHINGLES {�)
License Class G3 1' C KO Llc.Number �D a D 9 O W A r❑ �(/
(} - 31-9$ Cuif (loo�t'Nq SL+Slrykl OTHER(SPECIFY)
V
Date Contractor
OWNER-BUILDER DECLARATION �T PROPOSED DEC 157
I hereby affirm that I am exempt from the Contractor's License Lew for the following reason, Of'
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to nC
construct,eller,improve,demolish.or repair any structure,prior to its Issuance,also requires the BUILT-UP ROOF 0I1y
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor'°License Law(Chapter 9(commencing with Section 7000)of Division 3 of the �C O
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to ASPHALT SHINGLES
a civil penalty of not more than five hundred dollars 1$500).): WOOD SHAKES
E]1.as owner of the property,or my employees with wages as their sale compensation,will do ❑
the work,and the structure is nol Intended or offered for said(Sec.7044,Business and Pmfei
alone Code:The Contractor's license Law does not apply to an owner of property who build°or. WOODSHINGLES
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 -
Issoldwithinoneyearofcompietion,the owner-builder 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
with a ccntrector(s)licensed pursuant to the Contractor's License Levi. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B B P.C.for this reason
Owner
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: C
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, 113 •] ���yyyl
as provided for by Section 3700 0l the Labor Cotle,for the performance of the work for which this
permit is Issued. I�� I� 9� e IC
EJ I have and will maintain Worker's Compensation the work
for Insurance,as required Is
by Section 3700 s /'s, /)U
_the Labor tion I for the performance of the work for which this permit le lseuod.My Workers 77
Compensation Insurance terrier and Policy number are: 1 �r Total
Carrier 1.-"rA Vl tx�i rvt 4[w,nf4r.� Policy No. -5 1 /
CERTIFICATE OF EXEM ION FROM WORKERS' PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE NC-]
(This section need not be completed if the permit is for one hundred dollars($100)or lees,)
I certify that In the performance of the work for which this permit Is Issued,I shall not am Joy
any person In any manner so as to become subject to the Workers'Compensation Laws of Call- All roofs shall be inspected prior to any roofing materi I being
torula. installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understan a Will comply with all non point
subject to the Workers'Compensation provisions of the Labor Cod°,you must forthwith comply PP p y
with such provisions or this permit shalgbe deemed revoked. S rce regulations.
I certify that l have read this application and state that the above Information is correct.l agree
to comply with all city and county ordinances and state laws relating to building construction,and All r of coverings to a CIa "O"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for Ira
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, 'Z, `��
judgments,costs and expenses which may In any way accrue against said City In coneaquance
of granting of this permit. NATURE OF APPLICANT 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