R 5460 ERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5460
REROOF PERMIT INSPECTION DIVISION PERMITEXPIRATIDN .
(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
1 WO Orlve_ RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
�^ VES E] If yes—I understand that a Class A
NAME 4V f T :Z:JQ rGl_ t4a•JI-1 roof assembly is required.
NO ❑ Initial I.C.B.O.k
ADDRESS aicali6yL�c"'y-Cl nli EXISTING ROOF COVERING
PHONE 909 • 5113 NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S �_—r
G. 160n7 i e A /t t—� n c TO BE REMOVED $� TO BE RETAINED
' NAME y 1Y\ VIA 0.Jt]'.l 1.41 a-t- IC��i7C1 OI
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
Liz 310 9•�g O B EX
' TJNQ
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER 9.9 ASPHALT SHINGLES ®'
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em Ilcensed under provisions of Chapter B(commencing wlth Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
( A9 INGLES ❑
License Class `�• tJ Lie.Number
D SH
OTH S IFY) ElDate Contractor
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the(allowing 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.License Law(Chapter g(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($500).):
❑I,as owner of the property,or my employees with wages as their sola compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Protea.
.Ions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES El
thereon,and who does such work himself or Ih rough 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-bullder will have the burden of proving that he did OTHER(SPECIFY) IG'L.l G'c<. Tile.not build or Improve for purpose of sale.).
❑l,as owner of the property,em exclusively contracting with licensed contractors to construct / q
the project(Sec.7044,Business and Professions Code:The Contractor's License Lew does not PROVIDE I.C.B.O.REPORT NO. I�•/
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
C]I am exempt under Sec, ,B&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: -308
❑I have and will malntaln a Certlflcate of Consent to self-Insure for Worker'.Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is dtl. $BseismicCo
❑1 have and will malntaln Worker's Compensation Insurance,as required by Section 3700 of / V
the Labor Code,for the performance of the work for which this permit Is lesuatl.My Worker's
Compensation
�I�neu�re�nceCar rier ane Policy number are: q p..e� 3 Total D
Carrier ✓ J Policy No.:I3'.9�'tXYk]9Q� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.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 ins work for which this permit Is Issued,I shall not employ t Y
any person In any manner so as to become subject to the Workers'Compensation Laws of Call- All roofs Shall be Inspa p to offing material being
fornia. installed. If a roof i l ed without first obtaining an
Date Applicant inspection,I agree to remove all ngyy,marttirials for inspection.
NOTICE TO APPLICANT: It,after making this Certificate of Exemption,you should become I'
subject to the Workers'Compensation provisions of the Labor Cotle,you must forthwith comply Applicant understakdh aHd will comply with all non point
with such provleons or this permit shall be doomed 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 relating to building Construction,and All roof coverings to b cls "or better.
- hereby authorize representatives of this city to enter upon the above-mentioned property for In. .—L/-/�
speedo)purposes.
(We)agree to aeva,pe Indemnify w entl keep I harmless me City of Cupertino against liabilities,
ence
judgments,gran,costs and expenses which may In any way accrue against said City In consequence
CHWs granting of permit. SIGNATURE OF APf11dCA'�dT AT
• 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY