R-5380 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5380
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
. BUILDING ADDRESS
T —.n .r_r�i rpp
1 O�5 E� AJS �°` �J RESIDENTIAL_SCOMMERCIAL OTHER
OWNER'S f HAZARDOUS FIRE AREA
I{„£ 4 YES E] If yes—I understand that a Class A
NAME l -(�NN x VG I�- roof assembly is required.
NO ❑ Initial I.C.B.O.b
ADDRESS 6 5�5 3 i F View S C IPt-rE x 0. EXISTING ROOF COVERING
PHONE NUMBER S 'Z «O S NUMBER OF EXISTING COVERINGS '
CONTRACTOR'S �\7 _ t�
NAME •� _L_ J �%�'Sd Ns R�SO�CNtri 1:.. µJG TO BE REMOVED 7 S TO BE RETAINED
ADDRESS �+ TYPE OF ROOF COVERING
CITY&ZIP 3 9Y �ht BAR( �a2 Lid. S_s , j�'r!!(
EX
PHONE 9 7�L- 1(YS"5 BUILT-UP ROOF ❑
LICENSE -�30��
NUMBER ASPHALT SHINGLE ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is in full force and
effect. WOOD SHINGLES // El Class C —39 Lic.Number 00
Date IT- /7- 47 Contractor ��aN OTHER (SPECIFY) t r
OWNER-BUILDER DECLARATIO PROPOSED v ED
I hereby affirm that I am 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 OCT
construct.alter,improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF [� 7199/7
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
. Business and Professionsof Code)or the.he Is exempt therefrom and the basis for the
applicant
to ASPHALT SHHJGLE Y:=_
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the�pplic�nt.o
a civil penaltyl o not more than,or y emplundredoyees
bears(h wage: WOOD SHAKES
❑I,as owner of the property,or to ded with wages as their sole compensation,will s- ❑
the work,and the structure is net Intended or offered for saie(Sec.7044,Business and Profes-
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLESElImproves 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) � ,RO$1.4 644KR
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 comrac.or(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sac. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATIONPERMIT FEE
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declaration: 4 /
.have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, / Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 6
permit Is Issued. I
XI have and will maintain Worker's Compensation Insurance,as required by Section 370001 � Seismic
the Labor Code,for the potormance of the work for which this permit is Issued.My Worker's Total Compensation Insurance carrier and Policy number are:
Carrier QGP AuG LA!D 4An.N/Jiyoncy No. 1283 TWO1 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed if the permit is for one hundred dollars($100)or less.) OJ/
I certify that in the performance of the work for which this permit is issued,I shall 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 bei
fornia, installed. If a roof is installed without first obtaining an
Date Applicant inspection;I agree to remove all new materials for inspection.
NOTsubject II.the Workers'CompeCE TO APPLICANT: nsation prroviafter sion�s ofthe Labor Code,you mrtificate of Exemption ust forthwith le Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. y comply source regulations.
I certify that I have mad 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 roof coverings to be class"C"o .tter.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against Iibllltles, �p-c.y -�f� If 01.1-7 g7g7
judgments,costs and expanses which may in any way accrue against said City in consequence
of the granting of this permit. SIGNATURE F APPLICANT DATE
. PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
_ INSP. DATE INSP. DATE l��Y p7 INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE al& T INSP. DATE INSP. DATE'
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION.
__ OFFICE COPY