R 5000 APPLICATION FOR CITY CUPERTINO
NUMBER R— 500 0
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT WITHINSXPIRESIF OWORKISNOT STARTED
ISSUANEOR
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
154w•F AS
RESIDENTIAL � COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
GU I I wt„„ (WW N(o a YES [:] It yes—I understand that a Class A
NAME
roof
c/ �� NO of assembly Is requiredtial I.C.B.O.N
r ADDRESS in Y ap -Dert� /
r (+iR� t EXISTING ROOF COVERING -
PHONE O Si 4(3 6,? NUMBER OF EXISTING COVERINGS
,t CONTRACTOR'S
,/ /eor)_ _M�® TO BE REMOVED TO BE RETAINED
NAME I LF�J ��
"TYPE OF
ADDRESS
clTv&71P 15 ,179
,1 !C l l M1IC
ass-�o t� EXISTING
PHONE BUILT-UP ROOF
LICENSE ({, 7"Q ASPHALT SHINGLES
NUMBER 3 ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Coda,and my license 16 In full force and
effect
WOOD SHINGLES
License Class Lie,Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that I am exempt from the Contractor's License Law for the following reason.
ISec.7031.5,Business and Professions Coda: 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 Ills a signed statement that he is licensed pursuant to the provialons
• of the Contractor's License Law(Chapter a(comment witnh,,Section 7000)of Division 3 of the
Business and Professions Code)or that he is exampt"PilliLefirbin and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any.apblic. ermlt subjects the applicant to
e civil penalty of net more than five hundred doll. !f5
❑I,as owner of the property,or my errtglpl8yee.wi see their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intend dtl oil r d sale(Sec.7044,Business and Proles
alone Code:The Contractor's License as pply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such Inas or through his own employees,provided that
such Improvements are not Intended or If r sale.if,however,the building or Improvement
Is sold within one year of completion,the n -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 Profeeamns Coda: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
with a contrectona)licensed pursuant to the Contractor's License Law. PROVIDE fill INSTALLATION SPECS.
❑1 am exampt u or Sac. ,B 8 P.C.for this reason
owner Date
O KER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and Wit maintain a Certificate of Consent to salt-insure for Workers Compensation,
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this L, Building
r
permit Is leaned. Seismic _
❑ neve and w111 the pert Workers Compensation Insurance,as requiredsu Section 3700 s 0 r� y ���/'I
the Leber Code,for the performance of me work for which this permit Is issued.My Workers {� d 1996 T s f Total
Compensation Ineurence earner and Policy number are: JO LJ
Carrler Policy No, Cir -Ur--t LPERMIT AUTHORIZATION DATE
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE - N.OQ
(This section need not be completed If 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 se as to became subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected prior to any r ofing material being
fornia. 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 provlelons 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 relating to building construction,and All rO fcgverings to be lass"C"or better. .r
hereby purpos representatives of this city to enter upon the above mentlonatl property for In /� I�� ,/ J�L
spectihereby
purposes. [/.d/L//y�1//.I/tel�t`
Menlo
agree to save,indemnify and keep harmless the City of Cupertino against liabilities, 6
. ollhe granting of title Permit, SIGNATURE
which they In any way accrue against said City In consequence 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY