R-5417 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R� 5 417
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
'
WITHIN DAYS PERMIT ISSUANCE OR
WI DANSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS (� (/�� }6 A /J
IlQ D �A 1,)+A (7/ A ' 1�C ' RESIDENTIAL COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA
CYES.❑ If yes—I understand that a Class A
-
NAME _• �� N roof assembly is required
kal I.C.B.O.W
ADORES P1 hAr D 9/':MEXISTING ROOF COVERING
� � q- 1518
R Q
NUMBER OF EXISTING COVERINGS
CONTRACTOR'
ll ( •�/1 TO BE REMOVED TO BE RETAINED
NAME T UU66 l�
CITY&ZP Y R COVERING
/t �� Y�ADDRESS
EXI N
PHONE ll" _ BUILT-UP ROOF ❑ �JJJ
LICENSE [�' ❑ /�
NUMBER S �U C ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
orf Di affirm that emlicensedsssunder provisions of Ceptor B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license i9 In lull force and
effect.
n�
WOOD SHINGLES
:5z-
Lice
n Clns C+ � • Llc.Number v+"�
Date Conar z4fl Ill JA A /Y1 OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION J PROPOSED
I hereby affirm that 1 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
construct,alter,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 Lew(Getter (commencing with Section]000)of 3 of.e
h for the
Business end Professions Code)or the.he le exempt therefrom entl the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dollen($500).):
El 1.as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
sionsCode: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 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 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 Nil INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICA ION 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 aelbinsure for Worker's Compensation, �� , 4 Buildin�
as provided for by Section 3700 of the Labor Cada,for the performance of the work for which this
permit is Issued. �,i� C Seismic
❑I have entl will maintain Workers Compensation Insurance,as required by Section 3700of
the Labor Code,for the performance of the work for which this permit is Issued.My Workers ��b
'Compensatig lnslnsur�n�ca c�arr/ier en,,�tl P^ol�y number ere: Q- / �/%• ` Total
C
1`.f l y' t r V r Policy No. V^ PERI /AYJTHORIZATION 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 lase.)
I certify that in the performance of the work for which IN III Issued,1 shall not employ
any person In any manner so as to become suDle the Workers'C enation Laws of Cali- All rootsshall be inspected prior to any roofing material being
forma./�. 9.7 installed. If a roof is installed without first obtaining an
Date g-/C;L Applicant inspection,I agree to remove all new materials for inspection.
subject the CE Workers'oP eras'Compefnsation after provisi this
of thelcate of Laborr Code,you mustforthwith become
amply Applicant understands and will comply with all non point
with such provisions or this permit shalt;be deemed rvokad, Source regulations.
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 =LA
be SS r after.
hereby authorize representatives of this city to enter upon the above-mentioned property for In- ///•••���
sp(We)purposes.
(We)ogre to save,indemnify and keep armless.he City ai Cupertino against liabilities, 1
judgments,costs and expenses which may In any way accrue against said CIN In consequence
-97
of granting of this permit. SIGNATURE OF APPLICANT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY