R 5722 PERMIT
APPLICATION
APPLICATION FOR CITY OF CUPERTINO UMBER R— 5722
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (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
cioloo "Wddr, 4 I/
RESIDENTIAL COMMERCIAL OTHER
OWNER'S 1�" 1 HAZARDOUS FIRE AREA
n � 0✓L . FU I�n � YES ❑ It yes—I understand that a Class
NAME LA/tL lir XXIIr WII _lA SSCLIJ��((XR..tUA 11 of assembly Is required.
�/ N Initial I.C.B.O.It
ADDRESS&150 AYICC6L fitA .II) r/ G EXISTING ROOF COVERING
/
PHONE 1Y 50 , 5n — - NU BER OF EXISTING COVERINGS '
CONTRACTORS' ,a C
NAME—_ / I VLC�✓ �l L'Ng TO BE REMOVED I TO BE RETAINED
ADDRESS , �� (T TYPE OF ROOF COVERING
CITY B ZIP LL CJ J�/
EXISTING
PHONE �" " y /o 'ySS BUILT-UP ROOF ❑
LICENSE /-7
NUMBER ASPHALT SHINGLES El
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
affect.
WOOD SHINGLES ❑
License Class C-37 Lic.Number
Date If 12-9-7 Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that 1 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
construct,after,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 8(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 KR-sl
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).): WOOD SHAKES E3❑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 Plates.
clone 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.If,however,the building or Improvement
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contactor,to construct
the project(Sec.7044,Business and Professions Code:The Contractor's 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.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: ,ryry, T
❑I have and will maintain a Certificate of Consent to self-insure for Workers Compensation, g� A B DBuilding olrola
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is Issued. Seismic
l have and will maintain Worker's Compensation Insurance,as required by Section 3700 o1 /M
the Labor Code,for the performance of the work for which this pormlt Is Issued.My Worker's W toTotal
Cc pens °n Insurange carrier tl P ImNnu bar are:
Carriern1fY, �/� I Panay No. 09,07(oO iy fBMITL,. HQRIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need not be completed If the permit Is for one hundred dollars($100)or lose.)
I certify that In the performance of the work for whit Ihls permll la Isauetl.I shall not employ
any person in any manner so as to become subj 1 it
�e workera:Bem atlon Laws often- All roofs snail b in acted prior to any rat f' g ateria sing
fernla. JQ$/ /f installed. If a roof is installed without first obtaining an
Date �l-'��cJ>7 Appncam tg` // (f y inspection,I agree to remove all new materials for inspection.
subject toE a WorrkeaTO CCom efneat orn provisions of theflcate of Laborr Code,youExemption,you should become Applicant understands and will comply with all non point
with such provislons or this permit shall be deemed revoked. you must forthwith comply source reg lations. p y
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 to f Brings SS°C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,pe Indemnify w antl keep harmless the City ai Cupertino y In con liabilities,judgments,coals and expenses which may In any way accrue against said City in consequence
of the gaming of this permit. SIGNATURE OFAPPLICANT 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