R 5089 PERMIT R_ 5089
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (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 ,/
a a 9 ► 02 a 9 9 1T��Q 6��1(l RESIDENTIAL !!!!� COMMERCIAL OTHER
OWNER'S /`� //� q �� f HAZARDOUS FIRE AREA
NAME �� rl"' % blyl e � IJiI s YES ❑ It yeas asseundembly
is req that. Class A
ool assembly Is required.
% NO 'Ipr� Initial I.C.B.O.k
ADDRESS
��0 �T�yl� /�(/ EXISTING ROOF COVERING
g�r_��`- -
r PHONE
NUMBER OF EXISTING COVERINGS /
CONTRACTOR
/ �, TO BE REMOVED TO BE RETAINED
NAME l d7 � /
/Q 3 (y a �/ /� �� - A^� //�,�'�, TYPE OF ROOF COVERING
� ADDRESS ` Q !� ./(�[ t r,G('GC r'V`y
clTvTazlP_ / EXISTING
PHONE VI.Gcv , 40 L/ 3 - / z
BUILT-UP ROOFLICENSE
❑
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES 0�
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect 1 ��2 WOOD SHINGLES ❑
License CI a Lic,Number J
39
Date �( txe_ Contractor OTHER(SPECIFY)
OWNER-BUILDER DECLARATION UPROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
(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 y' cls
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions Ir GAY
• of the Contractor's License Law(Chapter a(commencing Win Section 7000)or Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES n
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to ®� �JJU��
a civil penalty of not more than live hundred dollars($500).):
❑l,as owner of the property,or my employees with wages as their sole compensation,wilt do WOOD SHAKES
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles.
dons Code: The Contractor's License Lew does not apply to an owner of property who builds or WOOD SHINGLES CITY Ir Ur L. 'Gr'i IINU
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.ll,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.).
❑1,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.
sppty to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractor(B)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
p 1 am exempt under Sec. ,B a P.C.for this reason
Owner Dare
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, Building 7 420as provided for by Section 3700 of the Labor Code,for the performance of the work for which this _
r permit lave ntl. �p 9,( OO seismic �' `OU
1 ❑I have and will the performance
Worker's Compensation the workfor Insurance,as required by Section 3700 of /// ( V
.the Labor Cade,for the performance of the work for which this permit Is issued.My Workers �,YUU
Comport tion I sur a carrier
,,and
,Policy number are: 'I Total
Carrle" n V y e lt1"' Policy No.LA�) PERMIT AUTHORIZATI N DATE
CERTIFICA E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ 4
(This section need not be completed It the permit is for one hundred dollars($100)or leas.) Q� h7v' .LiC.Gz
I certify that In the performance of the work for which this permit is issued,I shall not employ
any person In any ginner so es to become subject to the Workers'Compensation Laws of Cali- All roof.^.shall be inspected prior to any roofing material being
fornia. /' installed. If a roof is installed without first obtaining an
Dare 1 6 Applicant ' inspection,I agree to remove all new materials for inspection.
NOTICE APPLICANT: If,alter making this Certif rn AA of Exemption,you should become A understands and will cora
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant ply with all non point
with such provisions or this permit shalfbe deemed revoked. SOUfCe fB9UIatIOnS.
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 class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
sp(Wfon purposes.
(Wel agree to save,indemnity and keep harmless the City ai Cupertino y Inagainst liabilities,
' judgments,costs and of the granting of this parrmltsea which may In any way accrue against said Clry In consequence SIGNATURE 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