R 5734 PERMIT R_ 5734
.
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
1 SO DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
2T00(QO �oC�v��u c o
RESIDENTIAL COMMERCIAL OTHER '
OWNER'S POOP—ALL- HAZARDOUS FIRE AREA
NAME �`�' Y —�w�-a-
YES
11 eassembly is I srengd'iretd. Class
_^ '''y NO Initial I.C.B.O.B
ADDRESS I 5a)G/a Y(Ij/L1 e� EXISTING ROOF COVERING
PHONE ,5a — 5% •' NUMBER OF EXISTING COVERINGS
CONTRACTOR'S . c '^y
NAME C. J ✓ r�OCI LAn-C TO BE REMOVED / TO BE RETAINED
ADDRESS 2 C.t'1_ V1 I II _ A YJ I TYPE OF ROOF COVERING
CITY&ZIP �f�7A(15y! A U �? VA EXISTING
PHONE �t1 S G7r�'—�SSt BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LI ENS d underCONTRACTORS DECLARATION
I hereby inion that I em licensed under Professions
of Chapter 8(commencing with Section WOOD SHAKES 'CR�1
7000)of Division 3 0l the Business and Proleselone Cotle,and my license Is In lull tiros and
affect. WOOD SHINGLES ED
License Class� LIC.Number
Date /
r J—/�—��7 contractor OTHER(SPECIFY) ❑
�
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am 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
conetruc6 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's License Law(Chapter a(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 violatlon of Section 7031.5 by any applicant fora permit Subjects the sopllcant 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 sole compensation,will do WOOD SHAKES ❑
the work,and the structure le not Intended or offered for sale(Sec.7044,Business and Profes-
sions Coact:The Contractpre License Law does not apply to an owner of property who bullas 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.It,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he aid OTHER
not build or Improve for purpose of sets.). (SPECIFY) ❑
❑I,as owner of the property,am exclusivey contracting with licensed contractors to construct
the project(Sac.7044,Business and Professions Cade: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 Law. PROVIDE MFGR.INSTALLATION SPECS.
[31 am exempt under Sec. ,B&P.C.for this reason
Owner oats
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PE MIT FEE
I hereby affirm under penalty of perjury one of the fallowing declaration: P
r]
I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, Ir Lidding
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is ivedea' 2 VO Seismic
❑I have and will maithe pelf Worker's Compensation the work
which ce,this pe required Is I su Section 3700's NOVY`;7 FY
the Labor Cotle,for the performenc of the work for which rale permit le Issued,My Worker's '
Cc pen a��fpinn�Insurance carrier en oIff/gl'�humb rare: �t �'] Total
Carrier r •/n per . ^x f Pg11cy Nd. j0 &/ a RMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(This section need not be completed If the permit Is for one hundred dollars($100)or lees.)
I certify that In the performance of the work/or who h Ihla permit Is
issued shell not employ
any person in any manner so as to become sub ct the Worker' p aetlon Laws of Call• All roofs S dl nspected prior to an r00 Ing alert being
fernia' installed. If a roof is installed without first obtaining an
Data/A /7 - Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: 11,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP p y p
with such provisions or this permit shall be deemed revoked. Source re ulations.
I certify that I have read IWO 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 f �vBrings B lass"C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes.
IWO)agree to save,Indemnity and keep harmless the City of Cupertino ageonat liabilities,
luogmanta,costa and expenses which may In any way accrue against said City In consequence
of he 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