R 5964 PERMIT R_ 5 9 6 4
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION PERMIT XPIRATION
REROOF PERMIT � (408)777-',3'2'28 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR IMMU
ISO DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS /
RESIDENTIALy COMMERCIAL OTHER
OWNER'SS� HAZARDOUS FIRE AREA
/ �./nA
_114., C� !/� VES ❑ If yeas I assembly
req that a Class A
NAME C.LLLC/-cr�� 5 0 !/' �B T roofs—lural Isandthat
' y� NO ❑ Initial I.C.B.O.#
ADDRESR 4&07_&&1 1/'�'S//�.+. .4�' ��U EXISTING ROOF COVERING
PHONE O �' 9 NUMBER OF EXISTING COVERINGS /
CONTRA OR'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS �-y 5 `�-, TYPE OF ROOF COVERING -
CITY&ZIP -/ �J®
EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRA TORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section W D HAKES ,[QI'
7000)o1 Division 3 of the Business and Professions Code,and my license Is In full force and /r
even /# 2�/ G1/J/� �' S[j SHINGLES ❑
License Class y—y.L—[— Llc.Number ! �/"
Data Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that 1 am exempt from the Contractors license Law far the fallowing reason.
(Sac.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 slgnod statement that he Is licensed pursuant to the provisions
Of the Contractor.License Law(Chapter 9(commencing with Section 70001 of Division 3 of the
• Buslnes i and Protossions 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 live hundred dollars($500).): WOOD SHAKES
[3I,as owners(the property,or my employees with wages as their sole compensation,will do
the work,and the structure Is not Intended or Offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractor's License Law tloes not apply to an owner of property who bulltls 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 Ilcensed contractors to construct
the project(Sec.7044,Business and Profeealons Code:The Contractors 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 D ��
with a c m exempt licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.�Q
❑I 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 Worker's Compensation,
7r
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Building/
QQ
permit Is Issued. ��� /'�/OO A I r Seismic /, 00
❑I have and will themaintain Worker's Compensation Insurance,as permit is i su Section Worker's
'
the Labor Cotle,for the pertormenc f the work for which tela permit is issued.My Workeie / DQ
Compens on Insurance carrier a (1 umber re: �J� Total I _
all 90 ANNI".
carr 6ollcy N� e �QD PERMIT AUTHORI I N DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' ��
COMPENSATIONitIs INSURANCE N.OI] /'['�^ }w(uY (Jf;,— Llt ffV
(Tela section need not be come of the
It the permit le for one hundred dollars(5100)or to �,J V 1 c bJ
I certify that In the performance of the work for welch this permit Is Issued, shall not em toy 0
any person In any manner so as to become subject to the Worker.'Compensation Laws of all- All roofs shall be inspected prior to any roofing material being
finale. 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: 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 mpP
e Labor Code,you must forthwith comply
with such provisions or this permit shall be deemed revoked. source regulations.
I certify that I have road 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 constructlon,and All roof co eli ato be class 4 or better.
hereby authorize representatives of this city to enter upon the abova-mentioned property for in-
spection purposes.
(We)
(Wel agree to save,Indemnify and keep harmless the City of Cupertino against Ilebllltle9, v 7
ludgmonis,costs and expenses which may In any way accrue against said City In consequence
of the gmmmg m this permit. SIGNATURE OF A LICANT 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 - /�