R 5038 PERMIT R_ 503
8
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN ISO DAYS OF PERMIT ISSUANCE OR
• , 180 DAYS FROM LAST CALLED INSPECTION.
WILDING ADDRESS
7S PO /C A /ti u.J -D R°f
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME roof assembly is required.
NO ❑ Initil I.C.S.O.It
ADDRESS EXISTING ROOF COVERING
} PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
r
NAME -- 4 A A-"4; E _ZC1-X /C O n F tiJ ,6 TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITYBZIP /S-s / O G�41L �' e-zilc' i ¢L11
/sic 0 .c'6'.�+-�✓ ��<c c�9 - 1'S o,3 7 �
PHONE -��e 0 e] 7 7 :2 Yr ?8' BUILT-UP ROOF
LICENSE
NUMBER SPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES El
700
of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
C 3p / 7 y s WOOD SHINGLES ❑
Cleanse Claes / Lie.Number
Data
�1 9— 9 4, Contractor Oe e &d2Crt2.:tf A-ISa ' SPECIFY) ❑
OWNER-BUILDER DECLARATION I hereby affirm that I em exempt from the Contractor's License Law for the following reason.(Sec.7031.5,Business entl Professions Code: Any city or county which requires a permit toconstruct,alter,Improve,demolish,or repair any structure,prior to its Issuance,also requires the ;;FD
ROOFappllcantlorsuchpermittofile a signed statement that he is licensed pursuant to the provisionsof the Contractors License Lew(Chapter g(commencing with Section 7000)of Division 3 of theBusineea entl Professlona Code)or that he la exempt therefrom end the besla for the alleged INGLE$ AUG6 1996
exemption.Any violation OI Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).): WOODS AKES
❑I,as Owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Proles. L I I Vl Qur vi t I IIIIJ
along Code: The Contractor's 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.II,however,the building or improvement
is sold within one year 0l completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
01.as owner of the property,em exclusively contracting with licensed contractors to construct
the project(See.701 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 Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
01 am exempt under Sec. ,B 8 P.C.for this reason
Owner oats
WORKERS COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: 7
01 have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, &0 BuildingJ
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this !oo
'+ permit Is Issued. L
0 "In
have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Seismic �.
f ,the Labor Code,for the performance of the work for which this permit Is Issued.My Workers
Compensation Insurance carrier and Policy number are: Total
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the permit Is for one hundred dollars($100)or lags.)
1 certify that in the performance of the work for which this permit is issued,1 shall not em loy
any person In any manner so as to become Subject to the Workers'Compensation Laws of ell. All ts snall be Inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Data_8-9—�� Applicant r Of —--- inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: II,after making this Certificate of Exampll ,you should become Applicant subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP understands and will comply with all non point
with Such provisions or this permit shall be 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 relating to building construction,and All roof coverings to be class"C"or better.
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, G-
judgments,costs and expenses which may In any way accrue against said City In consequence
of the granting of this permit. SIGNATURE 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