R-52824b
it,
APPLICATION FOR
REROOF PERMIT
211 t 12 0_Qr10_r+ C bU.r+
NAME 1 r 1 ^"' O, PA -r . P •y
CITY OF CUPERTINO
INSPECTION DIVISION
(408)777-3228
ADDRESS2!4 or,�1,� ` VW •T�
CITV&ZIP �rj 2��1
PHONE '4 ✓"�' ' • � `� -
LICENSE
NUMBER LU (/ _O q Qk 7
-ep
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code. and my license Is In full force and
eHe�ot.!/I ^BillC %YcA�sO �lea Llc. Numper l/Vn Ci/S
Dole Contractor
OWNER -BUILDER DECLARATION
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
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Lew (Chapter 9 (commencing with Section 7000) of Division 3 of the
Susinese 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 or a permit subjects the applicant to
a civil penalty of not more than five hundred dollars ($500).):
❑ 1, 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 (Sae. 7044, Business and Protest -
alone Code: The Contractor's License Law does not apply to an owner of property who builds or
Improves thereon, and who does such work himself or through his awn employees, provided that
such Improvements are not Intended or offered for sale. ll, however, the building or Improvement
Is sold within one year 01 completion, the owner -builder will have the burden of proving that he did
not build or Improve for purpose of sale.).
❑ I, 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 tloes not
apply to an owner of property who builds or Improves thereon, and who contracts for such project.
with a contractors) licensed pursuant to the Contractor's License Law.
❑ 1 am exempt under Sec. ,B 8 P. C. for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑ I have and will maintain a Certificate of Consent to soil -insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Cotle, for the performance of the work for which this
permit Is Issued.
Athave and will maintain Worker's Compensation Insurance, as required by Section 3700 of
ih bor Coda, for the performance of the work for which this 1 permit Is Issued. My Worker's
Compen tl n Ins rence rler antl ollcy number are: I�,/�1r7l(O —Q-7�Q''��--''////
Carrle� Poll tis --/-lid( , '
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 less.)
I certify that In the performance of the work for which this permit Is issued, I shell not employ
any person In any manner so as to become subject to the Workers' Compensation Laws of Cali-
fornia.
Date Applicant
NOTICE TO APPLICANT: It, alter making this Certificate of Exemption, you should become
subject to the Workers' Compensatlon provisions of the Labor Code, you must forthwith comply
with such provisions or this permit shall be deemed revoked.
I certify that I have read this application and state that the above Informetlon is Correct. I agree
to comply with all city and county ordinances and state laws relating to bulltling construction, and
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We) agree to save, Indemnity and keep harmless the City of Cupertino against IleDllitles,
judgments, costs and expenses which may In any way accrue against said City In consequence
PRE -INSPECTION:
DATE I INSP.
NUMBER R- 5282 .
PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
RESIDENTIAL COMMERCIAL OTHER
VES ❑ If yes — I understand that a Class A
roof assembly is required.
NO Initial I.C.B.O. q
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
TO BE REMOVED l TO BE RETAINED
I•r�uea�•r�.L�
EXISTING
BUILT-UP ROOF ❑
SHINGLES ❑
WOOD SHAKES X
�VQOQ SHINGLES ❑
C
PROPOSED
BUILT-UP ROOF ❑ PAI
ASPHALT SHINGLES EW 17 REFI
WOOD SHAKES �+
C IY Ut LurtHCINO
WOOD SHINGLES ❑
• z, Pi{lfi
PROVIDE MFGR. INSTALLATION SPECS.
APPLICATION DATEI VALUATION I PERMIT FEE
^^
Building/6 it
gllD`Q_7 14,Q Z i^^��Q � Seismic U_
{{ Total /GSf• 95""
PERMIT AUTHORIZATION DATE
All roofs shall be inspected prior toffy roofing material being
installed. If a roof is installed without first obtaining an
inspection, I agree to remove all new materials for inspection.
Applicant understands and will comply with all non point
source regulations.
All roof coverings tobeclass "C" or better. I
l C1�fGlu.rt�,1�i11.Q2�1t,� 4/10
SIGNATURE OF APPLICANT I DATE
IN -PROGRESS:
INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY