R-5293APPLICATION FOR
REROOF PERMIT
21"''I Avw--
NAME
ADDRESS G' k4o I pqalrl0 'l rte'"
CITY OF CUPERTINO
INSPECTION DIVISION
(408)777-3228
PHONE I 4_J -S— 54'+1
r CONTRACTOR'S
NAME 'r /�j�Je
e ��..rlL �f/�Jc�`ST�{l�V. �iN�• /�,['T
ADDRESS ��/� �,G.IYtL.v—t �h✓L<�D-Se. /�71�1
- CITY 8 ZIP � - l 1
PHONE L"2 Z _44 !1
0
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Prolesslons Code, and my license Is in full lama and
effect. j
License Class C— 3e—!f Lic. Number —I •c�'� D I^'
Data 2�� ^�'� O_ y Contractor`'
OWNER -BUILDER DECLARATION
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
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
Business 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 for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars ($500).):
❑ 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 sate (Sec. 7044, Business and Profes.
sions Code: The Contractors License Law does not apply to an owner of property who builds or
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
not build or improve for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not
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 Contractors License Law.
❑ I am exempt under Sec. ,B 8 P. C. far this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
CI I have and will maintain a Certificate of Consent to self -insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Code, for the performanco of the work for which this
permit is issued.
.ETT%ave and will maintain Worker's Compensation Insurance, as required by Section 3700 of
_the Labor Code, for the performance of the work for which this permit is issued. My Workers
Compensation Insurance carrier and Policy number are:
4 -Policy Na.i a qp. p A
24
Carrier � IZ o I
CERTIFICATE OF E%EMPTI N FROM WORKERS'
COMPENSATION INSURANCE N.C.F7
(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 shall not employ
any person In any manner so as to become subject to the Workers' Compensation Laws of Cell.
forma.
Date Applicant
NOTICE TO APPLICANT: II, efter.making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
with such provisions or this permit shal0be deemed revoked.
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
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes.
(We) agree to save, Indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costs and expenses which may in any way accrue against said City in consequence
of the arantina of this permit.
PRE -INSPECTION: I PLYWOOD:
DATE I INSP.
NUMB PERMIT 5293
PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
RESIDENTIAL COMMERCIAL - OTHER
YES ❑ If yes — I understand that a Class A
NO roof assembly is required.
Initial
—
NUMBER OF EXISTING COVERINGS
TO BE REMOVED TO BE RETAINED D
TYPE OF ROOF COVERING
EXISTING
BUILT-UP ROOF
❑
ASPHALT SHINGLES
❑
WOOD SHAKES
SHINGLES
❑
ZWOAD
R (SPECIFY)
P A I -
y �v OOF MAR - 3 RE❑CI
,a ur uUrtrl�rvo
OeAKES ElWOODLES 1:17TQe
OTHER (SPECIFY) X
PROVIDE I.C.B.O. REPORT NO.
PROVIDE MFGR. INSTALLATION SPECS.
VALUATION
,U vr-V �� I 1 5.5—r -
I PERMIT AUTHORIZATION I DATE I
All roofs shall be inspected prior to any roofingterial being
installed. If a roof is installed without firstPbtaining 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 t/o/ /beass Ja better.
I -G /ViX0CANV ATE l7
SIGNATURE OF A— PL�ICAN- DATE
INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY