R 5589 ' APPLICATION FOR CITY OF CUPERTINO NUMB R R- 5589
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
fitoll!\Oo \
RESIDENTIAL � COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
y` / /� YES ❑ 11 yes—I understand that a Class A
NAMEPQC mill 14 Za ADA roof assereblyis required.
NO X Initial I.C.B.O.#
GAO EI G� 5444 YYL-m1 2510 5k~ 6rftz lvd EXISTING ROOF COVERING
PHONEO 885- v NUMBER OF EXISTING COVERINGS
CONTRA R'S nn' J���
NAME50-f J j4 I� IG.00 FI r1Cx � �S V Si�.�+S TO BE REMOVED TO BE RETAINED
ADDRESS ^� ''T' �9 I 7 TYPE OF ROOF COVERING
CITY&ZIP t4-Q J { ' r"1� ^� ko � Ems+ / 51I v EXISTING
BUILT-UP ROOF
LICENSE
NUMBER ASPHALTSHINGLES ❑
LICENSED
underCONTRACTORSsof Chapter 9(N 1:1
hereby affirm that I em licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES
7000)of DIVISIon 3 of the Business and Professions Code,and my license is In full force and
effect ��//� ^ A WOOD SHINGLES ❑
License CIas&'3g• G.—.l�Lic.Number L� / 0
Dale
12-31- 915 Conlrecto 64 5 OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby Affirm that I am exempt from the Contractor's License Lew for the following reason. Rs A
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to P
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 sx,
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the ��99 �✓ q�
• Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLESOCT W
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars($500).):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES CITY UI- l,UirgiTINU
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes.
slons Code:The Contractor's License Lew does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his town employees,provided that
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
is sold within one year of complation,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑1,as owner of the property,em 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 for such projects
with a contractors)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
[II am exempt under Sec. ,B 6 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: ��►�x IS
❑ have and will maintain a Certificate of Consent to celbinsure for Worker's Compensetlon, Swo q I Building,\n
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.andSeismic
❑ have end will the pert Workers f the work
for Insurance,as required by Somali 370001 1J�
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's n
'Camps�z/eatlon Insurance carrier and Policy n mbar are: �V� Z3-41-7 1 � Total
Carriere��,bljL J•11(x MYJ Policy No3'S2a? PERMIT AUTHORIZATION DATE
CERTIFICATE OF 9 ON FROM WORKERS'
COMPENSATION INSURANCE N.C.0 0
(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,1 shall not am toy
any person In any manner so as to become Subject to the Workere'Compensetlon Lowe of&h. All roofs shall i specte prior to any fooling material being
fatale, ' installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree t ave all new materials for inspection.
NOTICE TO APPLICANT: II,atter making this Certificate of Exemption,you should become Applicant underst Inds a d will cam
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP ply with all non point
with such provisions or this permit shalljbs deemed revoked. Source regulation
I certify that)have reed this application and state that the above Information Is correct. agree
herebyto ty watt all cityrep and se county ordinances and ter u on he above-mentioned
prope 10I end A roof coverings t be SS°C"O better.
hereby authorize representatives of Ihle city to enter upon the above-menlionetl properly for Im
sp(We) purposes. O
(We)agree to save,expenses
and keep harmless the Cly o/Cupertino against Ilebllen e.
ofjudgments,gran coats and expenses which may In any way accrue against said Clry In consequence
of the granting of this permit. L41GA E O PPLICANT 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 k