R-5334W
OFFICE COPY
PERMIT R_
5334
APPLICATION FOR CITY of CUPERTINO NUMBER .
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
,
's-fe-oe/vis
RESIDENTIAL COMMERCIAL ✓ OTHER
OWNER'S
HAZARDOUS FIRE AREA
( /�
LQP_
YES ❑ If yes I tend that. Class A
that
NAME T� %� �Y _ _ M Q _ 1-'r (, _Y
root assembly (sand
assembly i
s
NO Initial I.C.B.O. it
/�, _
�/�r�
EXISTING ROOF COVERING If
ADDRESS Sd[_V_7[,Q�I1KALrPa -�
[/
CA �o //
"
j'�N�
PHONE
NUMBER OF EXISTING COVERINGS
CONTRACT 'S
TO BE REMOVED TO BE RETAINED
NAME in)r
ADDRESS /( u/ 1
�
k
TYPE OF ROOF COVERING
CITY & ZIP ��� � MA g,,z�' /�
EXISTING
�T e "J,oY3
PHONE y_/J�"
BUILT -UP ROOF
j196�-
NUMBER 8 U
ASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am 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 lull force and
]�
WOOD SHINGLES ❑
License Class LIC. Number "
/ Qc-39
-s-+^ / p �
J N
OTHER (SPECIFY)
Date / Contractor
OWNER- BUILDER 59CLARATION
PROPOSED
hereby from
hereby affirm that I am exempt from the Contractor's License Lew for the following meson.
exempt w for
C /A
(Sec. , Business and Professions Code: Any city or county which requires a permit is
r
construct, altar, improve, demolish, or repair any structure, prior to its Issuance, also requires the
applicant for such permit to flle a signed statement that he Is licensed pursuant to the provisions
BUILT -UP ROOF G'
of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
L
Business and Professions 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 five hundred dollars (S500).):
1, the do
WOOD SHAKES ❑
E] as owner of property, or my employees with wages as their sole Compensation, will
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Prefes-
alons 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) �A.1 ;.�ona
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 contractor(s) licensed pursuant to the Contractors License Law.
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 am exempt under Sec. ,B 8 P. C. for this reason
Owner Date
APPVICA ION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
�%
Buildin ��
I hereby affirm under penalty of perjury one of the following declaration:
711 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, 40
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit Is Issued. (v /,
/F
/T
/�"
p n
I l g/O
Zr—
Seismic
I have and will maintain Worker's Compensation insurance, as required by Section 3700 of
the Labor Code, for the of the work for which this is issued. My Workers
'r
.
/
performance permit
Compensation Insurance carrier and Policy number ere:
L�r4
Totalr <_q
Carrier �,✓y[�P� fJ9 aJ Policy No. ^ �y% �:
CERTIFI OF EXEMPTION FROM
PE IT AUTHORIZATION
DATE
, y?
- WORKERS'
. COMPENSATION INSURANCE N.C.Q
(This section need not be Completed If the permit is for one hundred dollars S1 00) or less.)
K J�
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 Call-
All roofs shall be inspected prio any roofing material being
fornla.
installed. If a roof is installed wit -first obtaining an
Date 'L3 / App 7
inspection, I agree to remove all new materials for inspection.
NOT C5 subject I. the TO APPLICANT:
Compensation pro�vls s of the Labor Code, you must forthwith lbcomply
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 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 ass) r tier.
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 liabilities.
judgments, costs and expenses which may In any way accrue against said Cary In consequence
of the granting of this permit.
ATUR 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