R 5954 PERMIT R_ 59
APPLICATION FOR clTv 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
Uniled P1, - RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ It yes-I understand that a Class A
NAME W jb A AS 2 -� l.:tAbO r:em0 roof assembly is required.
(l - IG NO _1 Initial I.C.B.O.q
ADDRESS1 /2 / On u e1�T�� �t 3 EXISTING ROOF COVERING '
PHONE 5- Q NUMBER OF EXISTING COVERINGS
CONTRACTOR'S -
NAME n TO BE REMOVED TO BE RETAINED
ADDRESSTYPE OF ROOF COVERING
CITY&ZIP ��°x..���c/-72� Los Q� � EXISTING -
PHONE T/O BUILT-UP ROOF ❑
NUMBER 9S ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I ems under provisions of Chapters(commencing with Section WOOD SHAKES
7000)of Division 3 0l the Business
end Professions Code,and my license is In lull force and
effect.
3YS/,- ❑
License Class G'39 Lic.Number WOOD SHINGLES�I
Date Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that 1 am exempt from the Contractor's License Law for the following reason. pe
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to �.T
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 provlelons
Of the Contractor's License Lew(Chapter 8(commencing with Sectlom 7000)of Division 3 or theJ
• Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES. jjty [�r+(ykY�
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to va
a civil penalty of not more than five hundred dollars($500).1: G Ut
C]1,as owner of the property,or my employees with wages as their sole compeneatian,wllltla WOOD SHAKES
the work,and the structure Is not Intended or allered for sale(Sac.7044,Business and Proles- r
°Ions Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES V ❑
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 Ono year of completion,the owner-builder will have the burden of proving that he did THER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(See.70".Business and Professions code:The Contractors License law does not VIDE LO.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects If
with a contractor(s)licensed pursuant to me Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,B 8 P.C.for this reason
Owner Date
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 sell-Insure for Workers Compensation, Building
as provided for by Sectlon 3700 o1 the Labor Code,for the performance of the work for which this g
permit Is Issued. pQ
❑ Seismic
I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of �� I O 9/QQ
the Labor Coda,for the performance of the work for which this permit Is Issued.My Workers ` Total I y8
Comp°nf�tion Insurance carrier and Ic 'mbyre:
tamer( ?9&440'*oIicyng y�ycQ� �d PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE - N.C.❑ �\�
(This section need not be completed If the permit is for one hundred dollars($100)or less.) J 05 A -T1•r
0• 0,_I.1 -92
1 certify that In the performance of the work for which this permit is Issued,I shall not employ O
any person In any manner so as to become subject to the Worker°'Compenaatlon Laws at call. All roofs shall be inspected prior to any roofing material being
fornla. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTCE become
subject Ito theOWorrkers'Compeinselon prolviAPPLICANT: I,after sionis of ths aheiLabor Code,rtifcate of you mustufothwllshouth 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 root c(o/vvee/�1r/�(]%o to be class"C"Or better.
herebyauthorize purposes,representatives of this city to enter upon the above-mentioned property for in-
spection
nt �8..�--
herebon purposes. LL
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, 7 Ip—9�-
judgments,costa and expenses which may In any way accrue against said Cary In consequence
• of the granting of this permit. SIGNATURE OF AP C T 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