R 5955 PERMIT R_ 5955 .
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERM!TAR.,
JL PEC ION DIv 28 PERMIT EXPIRES IF WORK TI NOT STARTED
�" WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
Dl/l fe RESIDENTII COMMERCIAL OTHER
OWNE HAZARDOUS FIRE AREA
NAM ,IOMdn 5�
NO
❑ If yeas understand is a�ihed. class
U bE/ �n� If yes fun s wired.
/ / ❑ Initial I.C.B.O.N
ADDRESS 7 2 7 I I i r //ATL/ Ill_940_3_3 EXISTING ROOF COVERING "
PHONE 6 U NUMBER OF EXISTING COVERINGS
CONTRACTO/ji S 1^I
NAME— /SDS S LAO ! lh pI TO BE REMOVED I TO BE RETAINED
ADDRESS /} 46y 4-&6L/ Q S t TYPE OF ROOF COVERING
CITY&ZIP �` /• O.x /q/�t�7✓ EXISTING
PHONE �(/Q SCS G 23 BUILT-UP ROOF ❑
LICENSE.
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES
-7000)of Divlelon 3 91 the Business and Professions Code,and my license Is In lull force and .
effect.
WOOD SHINGLES ❑
License Claes LIC.Number
Data Contractor
OTHER(SPECIFY) `Q ❑
OWNER-the Conn DECLARATION
License
PROPOSED
hereby affirm that em exempt from the Contractors License Lew,for the vires following reason.
(Sec.7031.5,Business and demolish,
or rep Cotle: Any city or county which requires a permit to
act,eller,Improve,to file asigned statement
any structure,Is license Issuance,also requires the BUILT-UP ROOF ���❑ �JJ
fthe applicant for such permit to Lila a signed r 9(commencing
that he le h Sectio pursuant to the Dro of the
of the Contractor's License Law(Chapter g(commeneing with Section]000)of Division 3 of the
• Business and Professions Code)or that he is exempt therefrom and the basis for the allegt totl ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicano Q
e civil penalty of not more than live hundred dollars($500).):
❑I,as owner of the property,or my employees with wages as theb sole compensation,will do WOOD SHAKES r1
the work,and the structure Is not Intended or offered for sale(Sec.7044,Buslness and Profes-
slonsCode:The Contractors License Law does not apply to an owner of property who builds orWOOD SHINGLES ❑
Improves 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-bulmer will have the burden of proving that he did H (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(Sec.7044,Business and Professions Code:The Contractors License Lew does not PRO IDE I.C.B.O.REPORT NO.
apply to an owner of property who bulids or Improves thereon,and who contracts for Such projects l/
with a c m licensed pursuant to ins Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS. to
❑ emm ex exemptpt under
Sec. ,B B P.C.for this reason
Owner oma
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 Workers Compensation, Building I
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this g
141
permit is leaved. Seismic
❑ have and will the performance
Worker's Compensation which this as required Issued,
d,Section Workers 0l (�� I, _Gi0 M
the Labor Code,for the performance of the work for which Ihle permit Is lesuetl,My Worker's
Companef�on lnsurl carrier PoI rbar are: Total
�b p
came/, "� -- 6"1 Policy fOylD5417S0Q PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 A
(This section need not be completed It the permit Is for one hundred dollars($100)or less.) ,CE N T 0 0-1 - 1-7-99
1 certify that In the performance of the work for which this permit Is Issued,I shall not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of call. All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,alter making this Certificate of Exemption,you Should become Applicant understands and will cora
subject to the Workam'Compensation provisions of the Labor Code,you must forthwith comply pP ply with all non point
with such provisions or this permit shelrbe deemed revoked. Source regulations.
I certify that 1 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 civ gs to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In. l
sp ction(We) purposes. /f/
(We)epee to save,indemnity N end keep harmless the City ai Cupertino against Ilebllitms,
of the gran coats and expenses which may In any way accrue against said City In consequence
• gi the granting of this permit SIG RE 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