R 5614 r
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5614
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777- PERMIT EXPIRES IF WORK IS NOT STARTED
322$ WITHIN 180 DAYS OF PERMIT ISSUANCE OR
' 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
1 ICA RESIDENi COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
/� � I YES ye
NAME^uGU r 0JAIL1/0_I't, i��'TV"Sk� hoof assemblyssrequired Claw
/ / NO Initial I.C.B.O.q
ADDRESSEXISTING ROOF COVERING
PHONE ,7t— r'L NUMBER OF EXISTING COVERINGS
CONTRACTOR'S ,
< �,..,,,(/1 `� TO BE REMOVED TO BE RETAINED
NAME-1+11 �V UJ /�l.W-1 >� 1-rit C .
ADDRESS z // � �-t- TYPE OF ROOF COVERING
CITY 8 ZIP 39� �vLl l�9Cr.Q-eT .J c5. 5,5t EXISTING
PHONE— 7e2 ' �L��,) BUILT-UP ROOF ❑ y '
LICENSE - -
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter a(commencing with Section WOOD SHAKES ❑
7000)of Division 3 0l the licneec and under
provisions
Code,and mylicense Is In lull force and
effect. WOOD SHINGLES [�
Llcensa Class nssl Uc.Number +•54L " L"601
Date Contractor,
ro ' S—S 7 04/1 OTHER(SPECIFY)
B
OWNER-BUILDER DECLARATION PROPOSED /
I hereby affirmthatI am exempt from the Contractors License Lew for the linoafollowing reason.
(Sec.7031.5,Business and Professions or rep Code: Any city or county which requires a permit to %
applicant
alter,Improve,101116 signed statement
anystructure,he prior to Its Issuance,also requires the BUILT-UP ROOF � rYAAQB
eppllcent for such permit a LIle aChapt r 9(commencing
that g it licensedSection
7000)of to the provisions the ^e4IY
of the ss and Contractor's License Lew(Chapter S(commencing with Sectlon 7000)of for the 3 0l the y
Business end Professions Code)or that he s exempt therefrom and the basis for the applicant
to ASPHALT$RING S UY L[�A'
exemption.Anyviolationo t more
of Section hundred
by any applicant for a permit subjects the appllcenl Io (xLIPC'I!!t yQ
e civil penalty of not more Than five hundred tlollera($500).): V
01,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 Proles.
alone Code:The Contractor's 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) I`
not build or improve for purpose of sale.).
[11,as owner of the property,am exclusive contracting with licensed contractors to construct
the project(See.7044,Business and Professions Coda:The Contractors License Lew 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 contractors)licensed pursuant to the Contractors License Lew, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Date
Owner WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
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 Workers Compensation, BUlldjn�
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this �qq�
PermItI ued. III Seismic
have and will maintain Worker's Compensation Insurance,as required by auction 3700 of
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's
Compan tion Insurance carrier and Policy number are: Total
Carrier I , l Policy No. 1Z63.5 4`0 I PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEM TION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed It the permit Is for one hundred dollars($100)or lees.)
I certify that In the performance of the work for which this permit Is Issued,I shell not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of Cali- All roofs Shall be inspected prior to any roofing material being
torula' installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become
subject to the WorkereCompensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply With all non,point
with such provisions or this permit shall be deemed revoked. Source regulations.
I certify that I have read this application and stets that the above Information Is correct.I agree -
to comply with all city and county ordinances and state taws relating to building construction,and All roof covet gs to l �(-i°Or halter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In. r�
spection purposes. _ Q
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, �' / 7
ludpmare coats antl expanses which may In any way accrue against sold City In consequence 1
on hegrenIngefihiepermit. IGNAYU F P I 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY