R 5088 PERMIT R_ 5 $8
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
IN
WITH180 DAYS OF PERMIT ISSUANCE OR
WI IN 1 FROM LAST CALLED INSPECTION.
BUILDING ADDRESS t /
0700 ' 62��s O 67-0/,eeh,c RESIDENTIAL.J�COMMERCIAL OTHER
OWNER'S ,,.,// /,/7 " HAZARDOUS FIRE AREA
A57C �61kt /� U�//1&eby/�LUS YES ❑ If yes-assembly
is required a Class A
NAME Vu-v[ 777�����V���-l:U� J / ""' hof essembty is required.
�n NO Ltl Inrtlal I.C.B.O.B
ADDRESS C� 3 L EXISTING ROOF COVERING
�_ I
PHONE NUMBER OF EXISTING COVERINGS Cv Jw
CONI
�Ri'S
NAME Q�� TO BE REMOVED TO BE RETAINED
ADDRESS al? �A iqe ' !/G 1t I/ TYPE OF ROOF COVERING
CITY 8 ZIP U. �cL^�LC GL �G7 V
PHONE / LI/ EXISTING
BUILT-UP ROOFLICENSE
❑
NUMBER aa3 _ ASPHALT SHINGLES"' ❑
NUMBER Q
LICENSED CONTRACTORS DECLARATION n((,�rI``Aq��.,Q
I hereby affirm that I am Ilcensed under provision$of Chapter B(commencing with Section WOOD S RRCSf 0 199^
7000)of Division 3 of the Business and Professions Code,and my license le In full force and i.1) JJo
effect 3 WOOD SHINGLES ❑
License Clefs � Llc.Number �
Date contractor OTHER(SPECIFY) ❑
OWNER BUILDER DECLARATION 0PROPOSED
I hereby affirm that em exempt from the Contractor's Licence Lew for the following reason.
(Sec.7031.5,Business and demolish,
or rep Code: Any dry or county which requires requires permll to
consapplic nt.alter,Improve,to file signed air stateny mentrthat e,prior to lis Issuance,alsoprovii the BUILT-UP ROOF
applicant for such permit to Ills a Cloned statement that he with
Section
7000)of
the provisions the
of the ss an Pro License Lew(Chapter h(commencing with Section 7000)of for the 3 of the
Business entl violation of Code)or that he is exempt antfor a and the beefs for the scant to ASPHALT SHINGLES ❑
exemption,Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than,or hundred dollaemployees
with
wag.): WOOD SHAKES
❑I,as owner osthe propertyor Cmy eded or offered for
wegee aetheir sole compensation, rofdo s.
the work,and the structure Is not Intended ores not for sale(Sec.7044,Business entl Profen•
cions Code:The,an who
License Law di self or apply to
hiso n employers,who rovidebuilds or WOOD SHINGLES Improves thereon,entl who Jaen such workhimselffor or through his own employees,Improvement ed that ❑
such Improvements are not completion,
leb n,or offered for sale.11,however,the building or Improvement
Is not ld bull or
prove for purpose
sal owner-builder.111 have the burden of proving that he tlld OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contractin with licensed contractors to construct
the project(Sec.7044,Business and Professions Coda: he Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bunds or Improves thereon,and who contracts for such projects
with a contractor(a)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
El em exempt under Sec. ,S 5 P.C.for this reason
Owner Del°
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 Worker's Compensation, BUlldln�_
aemitIsitlfor by Section 3700 of the Labor Code,for the performance of the work for which this �I C{j
permit Is issued, (O/ /p $elsrrllik
❑I have and will the pelrf Woance f the work
for which ce,this as required u Section 3700's
the Labor Code,for the performance of the work far which iMe permit la Ieauetl.My Worker's
Compensatlo Insurance carper entl Policy number are: �,{� Total
Cerner Policy No�6�L? PERMIT AUTHORIZATION DATE
CERTIFICATE 6f EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p 240
(This section need not be completed It the permit le for one hundred dollars($100)or lose.)
I certify that In the performance of the work for which fire permit Is Issued,1 shell not employ
any person In any manner so as to become subject to the Workers'Compenaetion"we of Cali- All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
y/[�/
Date r+ f04 Applicant /6w,"� � inspection,I agree to remove all new materials for inspection.
NOTIC&O APPLICANT, If,after meking this Certificate of Exemption,you should become
subject to the Workers'Compensation 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 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 overings to beclass"C°Or better.
hereby authorize representatives of this city to anter upon the above-mentioned property for In. //
apache)agreeaea. ,1/e /] L(0�6
(We)agree b save,expenses
and keep hay way the cc City of Cupertino y n nstcon liabilities,
e, < N �O
of the granting
coats and expenses which may In any way accrue against said City n consequence U E APPLICANT DATE
• of the gr ECT of Nle permit,
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