R-5296 PERM
APPLICATION FOR CITY OF CUPERTINO
NU BER R- 5296
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS (J
-)- 115 SQA G uoX Ra- RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
VES f yes-I understand that a Class A
NAME �� I I OW1 1 4or I t y r ✓ roof assembly is required.
NO IJ IniI
ADDRESS 22^`115/y SO-4 ' Ju�� P(A • ) TING R C VERING
PHONE - "{3C NUMBER
a3S OF EXISTING COVERINGS 1
CONTRA(CTTOIR'S �/y
NAME f `U` 1 .0 (J� t G TO BE REMOVED t TO BE RETAINED
ADDRESS IL� 1Cr
TYPE OF ROOF COVERING
clTrazlPmba4�fySMJ66G(SII EXISTING
PHONE
� ) i[
BUILT-UP ROOF ❑
LICENSE -
NUMBER S13Ct�1 ASPHALTSHINGLES ❑ j)
LICENSED CONTRACTORS DECLARATION j
I hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and C
,fleet. ❑
G 5) �1
WOOD SHINGLES
License Class Lic.Number
Det. Lf—rZL+--g7 Contractor OTHER(SPECIFY) P A E e D
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to APR 24L-UV
construct,alter,Improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF T
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
• of the Contractor's License Law(Chapter 9(commencing with Section 7000)of DII 3 of the
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGL v'I Ur (�UejE L
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to Lam{T�lyN
o
e civil penalty of not more than five hundred dollars($500).): WOOD.SHAKES
C]1,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure is not Intended or offered for safe(Sec.7044,Business and Profes.
sions Coda:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES
improves thereon,and who does such work himself or through his own employees,provided that ❑
such improvements are not intended or offered for sale.If,however,the building or Improvement
is sold within one year of completion,the owner-builder will have the bu rden of proving that he did OTHER(SPECIFY)
not build or improve for purpose of sale.).
I]I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractor($)licensed pursuant to the Contractor's 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:
[ I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, BDIlding
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this I I I� M)�^^.�
permit is Issued. u (�(J
C]I have and will maintain Workers Compensation Insurance,as required by Section 3700 of Seismic
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's
Compena do Insurence sorrier an Polley number are: Total
C
arder L -LMnPolicy No. 129 4Q1 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE N.D,I]
(This section need not be completed If the permit Is for one hundred dollars($100)or loss.)
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 Law.of calf All roofs shall be inspected prior to any roofing material being
forms.
LJ-A`,4-q-7 installed. It a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTCE TO APPLICANT. Iof Exemption,
subject I.the Workers'Compefna tion prrevisionafter makinis ofertificate the Labor Code,you mut o thwlUhbecome comply Applicant understands and will comply with all non point
with such provisions or this permit shall be doomed revoked. source regulations.
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 All roof overings to be cl ss'
(Wbetter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spe) purposes.
(We)agree tocosts save,Indemnify entl keep h ny w as the Clta ai Cupertino y In co Iequence
ofthe granting of this perrmiand tses which they In any way accrue against said Clry In consequence SIGNATURE OF APPLI T 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