R-5113 PERMIT R_ 5113
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 A�DDREESSS
CfC. V �, RESIDENTIAL COMMERCIAL OTHER
OWNER'SHAZARDOUS FIRE AREA
!F D� A��q (V Z)56�..J U N)0 rJ [-}�� VES ❑ If yes s l understand firer'a Class A
NAME
�f assembly is required
�f0� /�/ NO Initial LC.B.O.N
ADDRESS.A k0W gg5lo�A� � EXISTING ROOF COVERING
PHONE
'j ��I NUMBER OF EXISTING COVERINGS I
CONTRA
//QQffT,�O.R���'S /�!/J!' _ n {� �S
NAME , t"A 657>4i IL�iIsF]"5 C C -.� INC— TO BE REMOVED—A TO BE RETAINED
ADDRESS `Z9Z LI,1COLN AVC-, 4JJ Gr'51 Zai TYPE OF ROOF COVERING
CITY aZIP—L� I- EXISTING
PHONE 4094'�� -�G`i�' BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES 11
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 full force and
effect' /// O�nry WOOD SHINGLES
License Class 3 Lid.Number �75& ❑
Date_ _T4 Contractor�r'AtsSAtJ�F. fAol OTHER(SPECIFY) 4o aICeirdV/
ARATION
I hereby affirm that I am exempt from h the Conttrracttor's License Law for the following reason. PROPOSED c4+D
(Sec.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 signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter a(commencing with Section 7000)of Division 3 of the
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($500).):
I,as owner of the property,or my employees with wages as their sola compensation,will do WOOD SHAKES ❑
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Profes-
slons Code:The Contractor's License Law does not apply to an owner of properly who builds or WOOD SHINGLES El
thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.It,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 licensed contractor.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 contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: A ' ^
❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, 6J 66 Bull
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this AUGermit Is Issued. pl
lel have and will maintain Worker's Compensation Insurance,as required by Section 3700 of m p �p I— SeIS IC
I bor Code,for the performance of the work for whicctl4ovoimrt is Issued.My Worker's C/7 Ur 4 VVV
'Compensation Insurance carder end Policy num r {,V q /Y Total
Carrier �I' `r CP�T PalliNo. Z42 — V� PERMIT A -.O TI DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.]
(This section need not be completed It the per It Is for one hundred dollars(8100)or less.)
I certify that In the performance of the work foEtc
full thla ermit is issued.I shall not employ
any person In any manner so as to become sub' tho rka omp lion Laws f call- All roofs shal a inspected prior to any roofing material being
fords. 4 installed. If a roof is installed without first obtaining an
Date !� - ' L� Applicant inspection,I agree to remove all new materials for inspection.
NOT CE TO APPLICANT: It,after subject t.the Workers'Compensation provisions of theicate L born Coda,you must forthwith omvly Applicant understands and will comply with all non point
with such provisions or this permit shalQbe doomed 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 r f covering t0 class"C"or bette .., y/
hereby authorize representatives of this city to enter upon the above-mentioned property for in- ; 7)• v —�+ V�
spection purposes. ,�///
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may in any way accrue against said City In consequence
of the granting of this permit. S NATURE 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