R 5035 PERMIT R_ 5035
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
180 DAYS FROM LAST CALLED INSPECTION.
. BUILDING AADD�DRESS • � ,
9 / VRE /�1n�,, ',� _ 610�—�"��yy� �n RESIDENTIAL 2� COMMERCIAL OTHER
OWNER'S J HAZARDOUS FIRE AREA
NAME _/��q �' P�-t/YlQ .( YES roof assembly streegtl Iiretd. ClessA
A
NO Initial LO
BO.
ADDRESS EXISTING ROOF COVERING
PHONE 40p a—J S —J 7 #
MBER OF EXISTING COVERINGS
' CONTRACTOR'
_��' e,yO qj TO BE REMOVED TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
�Q EXISTING
PHONE` I S1 —Q 6 BUILT-UP ROOF ❑
NIUMBER ;v—
n—Gor
� / ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 em licensed under provisions of Chapter B(commencing with Section OOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In full force entl
effect.
�l Jou
OD SHINGLES ❑
License Class �� Llc.Numbers D `� • �
Data 9 '/ Contract dr� ppO�Tp��PEC Y) ry ❑
I hereby affirm that I am exemptNrom h the ContrLIDERactors License Lew for the following reason. +-++ �� S6 P 111996
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct.Star,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 (✓I I i l.ri L•U, ❑,f IIq �
of the Contractor's License Law(Chapter B(commencing with Section 7000)of Division 3 of the CSS i25 /tn
• Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
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($500).):
E]1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure to not intended or offered for sale(Sec.7040,Business and Proles.
alone Code:The Contractor's License Lew does not apply to an owner of property who builds or WOOD SHINGLES
Improve$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 bund or Improve for purpose of sale.).
I,as owner of the property,am exclusively contracting with licensed contractors 10 construct
the project(Sec.7044,Business and Professions Code:The Contracefs 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 Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, /'
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Q/ /�� /��yyf ��, / Bullding
permit is Issued. / ��!/ 0 7 $eISR11C
Yl have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
th Labor Code,for the performance of the work for which this permit is Issued.My Workers
Compensation In ranee carr�ie"r end Policy number are: Total
Carrier M 7 POIIcyNo.571415--A)587 PERMITAUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed It the permit Is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any person In any manner so as to became subject to the Workers'Campaneatmn Law$of Celh All roofs shall be inspected prior to any ret)finb m6iterial being
fornla. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It.star r
subject to the Worrkers'Com ensalion ppeolvislonis ofethe lLabor Code,yocate of u
,you should become Applicant understands and will comply With all lion point
with such provisions or this permit shal,be deemed revoked. you must forthwith comply P Y
source regulations.
cepllfy that have read oletyapplication ordinances
State that the above Information tobuiding lecorrect.ioagree
to hereby authorize
all cep and se tabes at this
ncae end ter upon the
to property
and All roof cover'Rg to be s ass"C"or better.
hereby authorize reprasenlstivea of ihla city to enter upon Iha Sbovamentlonetl property for In-
ep(We) purposes. x+ /
(We)agree tocosts save,Indemnity entl keep harmless cc City of Cupertino againstcon Ilebllence 7 //
of the granting of this perrmiL and es which may In any way accrue against said City in consequence SIGNATOR OF APPLICANT W7 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