R 5762 APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5762
.
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
K/✓0 u
aLy� RESIDENTIAL-4COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA -
NAME r_— N I-To c,I'/ .T L=71/ YES ❑ If yes-I understand that a Class A
sof assembly is required
N Initial I.C.B.O.4
ADDRESS 10 3,27 V-77 KrioLL t3)V 1)- EXISTING ROOF COVERING
PHONE (+08) 7-4 -11 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S �p m /�
NAME ��_Z9A'N A �AI IC D o f-Z4Q 0, TO BE REMOVED - TO BE RETAINED
ADDRESS
I r1�'mF�.�� � TYPE OF ROOF COVERING
st Dp S Eta 9 EXISTING
PHONE�'� a 4'7— FM6 BUILT-UP ROOFLICENSE ❑
NUMBER �O Jr,3 SI`� ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION -
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with.Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
License Claes C-3 LIC.Number-n-6 S.�9Y7 WOOD SHINGLES ❑
Data �Q / 9 Q Contractor t /=- - �•��=�� OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
1 hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sac.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 El
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions l
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
' Business and Profesalons Code)or that he Is exempt therefrom and the basis for the alleged 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 five hundred dollars($500).):
❑I,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 sale(Sec.7044,Business and Profes-
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD 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.If,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 sate.).
❑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
with a am exempt
nrSe pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS,
❑I em exempt under Sac. ,B 8 P,C.for this reason
Owner DatAP♦,El ION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
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
as provided for it
Section 3700 o1 the Labor Code,for the performance of the work for which this U� g
permit le etl. h� rV JJff��jjys $eISmIC _y,�y✓
I'...
end will the performance
Worker's Compensation the Work
which this as requiredbySection 3700's , x1/1 ®
e Labor Code,fill the performance of the work for whirs this permit is d by S.My Worker's
Compensation Insurance carder and�U/il7Policy number are: pp f L'(/YC Total
Carrier 47E Policy No. L3b6733- 71 PERMITAUTHORI TION E
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.00
(This section need not be completed If the permit Is for one hundred dollars($100)or lees.)
I 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 became subject to the Workers'Compensation Laws of Can- 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.
TO APPLICANT: It.after makinou
subject toEthe Workers'Compensatlon provisionls of the Labor Code,Certificate of yolu onmust forthwllthbecome 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 coverings to be class"C"Or befter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spectiojud(We) purposes.
(We)agree s save,Indemnity and keep harmless cc City of Cupertino against liabilities,
ofthe gran caeca and expanses which may in any way accrue against ealtl Ciry In consequence
onna granting of permit, SIGNATURE OF APPLICANT U 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