R 5882 PERMIT R_ 5882
APPLICATION FOR CITY of CUPERTINO NUMBER
R-
PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to BUILDING ADDRESS
180 DAYS FROM LAST CALLED INSPECTION.
l , og6li Se -e ✓lixc 8 / 1/"
C –C.` TTI�S RESIDENTIAL' COMMERCIAL OTHER
owNER''(S11 - - HAZARDOUS FIRE AREA
NAME*& ( r 1 /s YES ❑ If ye _I understand that a Class A
roof assembly Is required.
.NO Initial I.C.B.O.N
ADDRESS �
a 4'c S' 1 �? / l r/r EXISTING ROOF COVERING
�
PHONE a J_ �7 �C T 7 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME �� f�� � Ta �� TO BE REMOVED TO BE RETAINED
APE OF ROOF COVERING
ADDRESS yp,
CITY&ZIP
EXISTING
PHONE We- 7�� — ZJ'� y �- BUILT-UP ROOF El
LICENSE
NUMBER 3 30 9 y ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect. WOOD SHINGLE ❑
License Claes Lic.Number
Data
Deto Contractor
OTHER(SPECT ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em 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,altar,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF 11appllcant Tor such permit to file a signed statement that he Is licensed pursuant to the provisions
• of the ss an Professions
License Lew(Chapter a(commencing with Section 7000)of for the ale theBusx�
exemption,
end violation of Code)or that he Is exempt applicant
tfora and the basis for the alleged ASPHALT SHINGLES
exemption,Anyviolationof Section 7031.5byany s($50 ).fora permit subjects the applicant to
a civil penalty of not more then flue hundred dollars($500).):
E]1,as owner of the property,or my employees with wages as their sale compensation,will do WOOD SHAKES ❑
the work•and the structure Is not Intended or offered for sale(Sec.7044,Business and Prcfes-
slons Code: The Contractor's License Lew 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 ownenbulider 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 6 P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the fallowing declaration:
❑I have and will maintain a Certificate of Consent to seff-Insure for Workers Compensation, Ulldln
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this g
permit Isissued.
XniT�� Seismic
❑ have and will the pelrf Workers Compensation Insurance,as repulsed by Section Worker's V
the Labor Code,for the performance of the work for which this permit Is Issued.My Warkere r(
Compensation Insurance carrier and Policy number are: 1/ T 7 p ® Total
Carrier—IS 71'*e Ck Policy No. G� z L/0— P RMI Pj,U IZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 �0
(This section need not be completed 11 the permit Is for one hundred dollars($100)or lees.) �G `
I certify that In the performance of the work for which this permit is Issued,1 shall not employ
any person In any manner so as to become subject to the Workers'Compeneetlon Laws of Cell. All roots shaVe bpected prior to any roofi g male/albeing
lornla. installs Sft a roof is installed without first obtaining an
Date Applicant inspectiin,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP p y p
with such provisions or this permit shell be deemed revoked. 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 raising to building construction,and All roof coverings to be clas better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(We)agree to save, Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,coats end expenses which may In any way accrue against said City In consequence
of the granting of this permit. $I TURE OF APP ANT 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