R 5229 PERMIT R_ 5229
APPLICATION FOR
CITY of cuPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS J /� 1
I q 4 -7 () 1{J,t cl-\w CO4 l—T, RESIDENTIAL COMMERCIAL OTHER
OWNER'S 11,, JJ 11 St - HAZARDOUS FIRE AREA
NAME �\ CLU N t C 1`l`V x r V YES ❑ roof
it ssembly 5 required. Class A
1 NO ❑ Initial I.C.B.O.W
ADDRESS I"( w7o R �h w poc� C.�• EXISTING ROOF COVERING
PHONE `-I �(,,q— 3 yc�5- NUMBER OF EXISTING COVERINGS
CONTRACTOR'S/,/n�'• I r
NAME VA S I//!�s I\�T�/L��q T TO BE REMOVED / TO BE RETAINED
ADDRESSCITY&ZP 1703 (,a 1JR. .�Rnlose ff/22 TYPE OF ROOF COVERING
L PHONE. HOC/ ,�>�^3S�S BUILT-UP ROOF
LICENSE
NUMBER 4307 , 160 ASPHALTSHINGLES Elt�
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect. 1/L' 0 qs- WOOD SHINGLES ❑ �/��
License Class `- Lt..Number
Date I t/I b I a�o contractor OTHER(SPECIFY) ❑
EAl
OWNER-BUILDER DEC RATION PROPOSED
I hereby affirm that I em exempt from the Contrecto License Lew for the following reason.
(Sec,7031.$,Business and Professions Code: Any city or county which requires a permit to �p 15
d ����
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 N
of the Contractor's 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 V t-tH I INU
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to Cltv il V
e civil penalty of not more than five hundred dollars($500).): WOOD SHAKES
❑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 Profes.
sions Code:The Contractors 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 Salo.ll,however,the building or Improvement
Is not
doln e for purpose
sale.).
owner-builder will neve the burden of proving that he tlitl OTHER(SPECIFY) ❑
not sold
within
rImproveneloopurpose of completion,the
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7a44,Business and Professions Code:The Contractor's License Lew does not PROVIDE I.C.B.O.REPORT N
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 Lew. PROVIDE MFGR.INSTAL N $ ECS.
❑1 am exempt under Sec. ,B$P.C.for this reason
Owner Dela
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this g
permit lav and 11—IS—O� orf O Seismic /•,O
❑ have end wirmeinterf WeanWorkers Compensation Insurance.as permit
by Section Worker's of 7
-the Labor Cods,for the performance of the work for which this permit Is laeuetl.My Worker's Q
Compensation Insurance terrier 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 less.)
I certify that In the performance of the work for which this permit Is issued,1 shell not employ
any person In any manner so as to become subject to Workers'Compensation Laws of Cali- All roof^ all be inspected prior to any roofing material being
fornla. inst ed. If a roof is installed without first obtaining an
Date it /131q& Applleant inspection,I agree to remove all new materials for inspection.
NOTICE subject totheWorrkeras'Compensationprroafter valoI Ithe11cers Labor`Code,youmustfothwlltlhbecome comply Applicant understands and will comply with all non point
with such provisions or this permit shal0be de a revoked. Source regulations.
I certify that l have read this application end a e 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 cc rings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
p(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, �s I 13 I q x0/
• of t a granting of this percosts and mit es which may In any way accrue against said Cly In consequence SIGN URE 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