R-5579 D
�� PERMIT R_
APPLICATION FOR � PERTINO NUMBER 5579
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1 W DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
C;�6`/l D�;f r^ Al (/ RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA�G'r YES ❑ If yes—I understand that a Class A
NAME of assembly is required
/� N Initial I.C.B.O.N
ADDRESS 0964�/ 2u'^� P� EXISTING ROOF COVERING _
PHONE (O /D NUMBER OF EXISTING COVERINGS r
CONTRACTOR'S
NAME a -YO BE REMOVED TO BE RETAINED
C �
ADDRESS —q/�Q / TYPE OF ROOF COVERING
CITY B ZIPSdfL/ 2 14,1 /10
EXISTING
PHONE � 7 BUILT-UP ROOF
LICENSE i
NUMBER ASPHALTSHINGLES
LICENSED CONTRACTORS DECLARATION /J /
I hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES ❑ �s/CI�P.^✓l/�C
7000)of Division 3 of the Business and Professions Code,and my license Is in full force and
effect. Ci;f —7 WOOD SHINGLES El
Clas `l U..Number
Date contractor r OTHER(SPECIFY) ElCIWNER-BUILDER DECLA TIO PROPOSED
hereby ffirm that em exempt train the Contractors License Lew for the lowing reason. P
(Sec.7031.5,Business and Professions Cotle: Any city or county which requires a permit to
acc pplicant aiteg improve,demolish,signed
or repair any ntrthat he prior to its Issuance,also requires the I PROOF AUG 1�REcro
of the Co for such permit to flaw a signwtl statement incl he Is licensedSection
pursuant to the provisions the E
of the ss and Pro License Law)or that h(commencing with om and 7000)of Division 3 wt the
Business and Professions Code)or that he Is exempt therefrom end the baste for the applicant
SPHALT SHINGLES ❑
exemption.Any violationelhan five
byany applicantfora permit subjects the applicant to uv�
a civil penalty of not more peen floe hundred dollars with
wage CITY UI• �/ �INU
❑Las and
er the structure
i not int y intended
ffered wages as(Sec.their sone compensation,sand
Prlil D WOOD SHAKES
the work,end the structure is not Intentletl ores not for sale(Sec.7064,Business and Proles-
s or
Improv Improves thereon,
Contractor's License Law tli does or throapply to an ghhiso own
property providehe that WOOD SHINGLES ❑ 1
Improves thereon,antl who does n such work himself or through els own employees,Improvement provided that
such Improvements are not Intended or offered for sale.If,however,the building or Improvemwnt .
Is sold within one year of completion,the owner-bullder 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,em exclusively contracting with licensed contractors 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 contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B It P.C.for this reason
Owner DateATIO APPLICATION DATE VALUATION PERMIT
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: ` 7 C(�
I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Bu as provided for by Sectio 700 of tea Labor Code,for the performance of the work for which this (J J (1�
permit Is Issued. ^�(] SBISffll
❑ neve antl main n W rkers Com se ion Insurance,as required by Section 3700 of
the Labor Co I for th ado once of work for which this permit Is issued.My Worker's
'Compensation nsu a nd P cy number ere: Total
Carrier — Policy No. a/ r7 PERMIT AUTHORIZATION D
CERTIFICATE OF EXPAMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit is for one hundred dollars($100)or fees.) —
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali- All roofs shqfte inipectilifizi prio r4ofillro mater a being
forma. installed. It a ro f is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT:p II,attar making
king this Certificate of Exemption,
mustulorphwllthbcomr la App' nt derstands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code, comply
with such provisions or this permit shallibe deemed revoked. so roe regul Vions.
I certify that I have read this application and state that the above Information is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction,and I roof CO rl s t be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spectlon purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, 1
judgments.costs and expenses which may In any way accrue against said City in consequence
of the granting of this permit. SI ATURE O PLICANT DATE
PRE-INSPECTION: PLYWOOD: -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