R 5928 PERMIT R_ 5928
APPLICATION FOR CITY OF CUPERTINO. NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
s 408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING DDRESS
101091 t r RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
1VES ❑ If yes-I understand that a Class A
NAME�jY)a h S CSD O r 1 I Yl d 32 ,roof assembly is required.
Initial I.C.B.O.q
^U
ADDRESS p I e QIP /�—�� NO ❑ EXISTING ROOF COVERING
PHONE Q p /S {� (p NUMBER OF EXISTING COVERINGS I
CONTRACTO
NAMER'
//,.', /-�• TO BE REMOVED TO BE RETAINED
�+ Q" "S OO �?
ADDRESSS 0 EXISTING
TYPE OF ROOF COVERING
CITY 8 ZIP &x 1726
C
PHONE UO — Z -3 BUILT-UP ROOFLICENSE
❑
NUMBER. S ASPHALT SHINGLES ❑
LICENSE15 CONTRACTORS DECLARATION /
heresy efftrm that I em licensed under provisions of e.Slid
a(commencing In with Section d WOOD SHAKES
]000)of Division 3 o he Bus a and Professions Code.e tl my license Is In lull orae and
eel.
Li WOOD SHINGLES ❑
License Cleae Uc.Number '
Date Contractor
OTHER(SPECIFY) �O ❑
SO
OWNER BUILDER DECLARATION PROPOSED B
I hereby affirm that am exempt from Co e: Any city License Lew for the following rasion.
(Sec.construct,
alter,5,Buelneee and Professions Code: Any city or county which requires a permit to
applic tit, ru Improve,to file signed air statement
eny menthatstructure,prior toIts!pursuant to o requires the BUILT-UP ROOF`�\� �vt❑
applicant for such permit License file a signatl r 0(co m that he la Ilce ctio pursuant to the pro of the
of the ss an Prossions Lew Chethat h(commencing with Sieben 7000)of Division ale the
•
Business end Professions Codes or that he is exempt ant Lara and the bails for the alleged ASPHALT SHINGLES J�V ❑
exemption.Anyviolationo t more
of than
ionfive hundred
by any s(plea)fora permit subjects the applicant to
e civil penalty of not more then Ilve huntlred tlollere($500).):
❑l,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES
the work,and the structure Is not Intended or offered for eels(Sec.7044,Business and Profea-
along Code:The Contractor's License Lew does not apply to an owner of property who builds or D SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvemanta are not Intended or offered for sale.If,however,the building or Improvement
Is Said within one year of completion,the owner-builder will have the burden of proving that he did 0 (SPECIFY) El
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 �/�I f
wane am
undelicenr
Sdpursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt antler Sec. ,B 8 P.C.for this reason
Owner Dale
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, Building 14 1
as provided for by Section 3700 of the Labor Code.for the performance of the work for which this
permit Is Issued.
❑ seismicC
I have and will maintain Workers Compensation Insurance,as required by Section 3700 of O"1
the Labor Code,for the performance of Do work for which this permit Is Issued,My Worker's
Compensatlt II ssuurraancabarrler antl P q i ears.: .�//�/� Total "1
CarnepLl='Y( ��Ne�6tTq(� 011cy No. t PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.[] T
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) V D'E A "'�0 0, -1-1-916
1 certify that In the performance of the work for which this permit a Issued,I shall not employ
any person In any manner so as to become subject to the WorkersComponsatlon Laws of Cell. All roofs Shall be Inspected prior to any roofing material being
fertile. installed. If a roof is installed without first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will with all non
Subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP comply p y 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 cov gs to be class"C°or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In- / /[1
ap(We) purposes. / 7— /f._
(We)agree to save,pe Indemnify w end keep harmless the City of Cupertino against liabilities, J/C�l�rw��+. 9
of tgmenta,coals and permit. a which may In any way accrue against said City In consequence
• olthegrantingofthis permil. 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