R 5364 PERMIT
APPLICATION FOR CITY of CUPERTINO NUMBER R" 5364
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(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 ,//J
L 10 S 5 RESIDENTIAL I COMMERCIAL OTHER
OVINER'S HAZARDOUS FIRE AREA o
! �]_ � ) VES ❑ If yeas understand that a Class A
NAME l i lc S I �-+✓ ` Z I / /C/�_ roof assembly is required.
It NO ❑ Initial I.C.B.O.#
ADDRESS [�S A-W--2 F 8 EXISTING ROOF COVERING
PHONE - 2-J -- R S NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME �NY1/ 2P 2 TO BE REMOVED TO BE RETAINED
ADDRESS m TYPE OF ROOF COVERING
CITY&ZIP 2-3' 1 Z EXISTING
PHONE 3 D `L I I BUILT-UP ROOF ❑
LICENSE
NUMBER 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. / c 7 52� D WOOD SHINGLES ❑ G
License Class Lt..Number
�� �` - OTHER SPECIFY
Data 6-4s=� -BUILDS DECLARATION
E - + (SPECIFY) ❑ /
OWNER-BUILDER DECLARATION PROPOSED -r /
hereby affirm that em exempt from the e: Any city License Law for the following reason. • ss`000 /�
(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 requlree the .��)ItiTIP gOOF ❑ ,/
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions r, 1' 1
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Divlelon 3 of the
Business and Professions Code)or that he Is exempt therefrom and the 18518 for the alleged .ASPHALT SHINGLES
• exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to p,lprp
a civil penalty of not more than five hundred dollars($500).):
IK
01,as owner of the property,or my employees with wages as their sole compensation,will do WO _Dt{S�1H]Ap
KES ❑
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 (r l 1 vi WOOD SHINGLES
L/�
❑
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-builder will have the burden of proving that he did OTHER(SPECIFY - Elnot build or Improve for purpose of sale.). ;
El 1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sac.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 contractor(s)licensed pursuant to the Contractor's License Law.
❑I am exempt under Sec. ,B 8 P.C.for this reason PROVIDE MFGRANSTALLATION SPECS.
Owner Dole
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
GV—t/—
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
,permit Is Issued, 1
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of ` I j 000 Seismic )) ' 0
the Labor Code,for the performance of the work for which this permit Is Issued.My Workers Q Total
/ �O
Compensation Insurencj carder entl Poles numberrre: _
Carrier C 1�F�iY+�aY V A 1/d71 .f/ Policy Na,c'-4
PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NO
' (This section need
the not r antecompletedof the
If the permit is for one hundred dollars($100)or lean) ✓_/ r-Q
1 certify that In the performance of the work for which this permit is Issued,I shell not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of can- All rodis shall be inspected prior to any roofing material being
Date' _ 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,after making this Certificate of Exemplar,you should become
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith 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 ardinancee and state laws relating to building construction,and All roof coverings to be class'195 Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes. ^�
wen: IO save,Intlemnity and keep harmless the City of Cupertino against liabilities, 6—G--.
Jud costa and expenses which may In any way accrue against said City In consequence
of the granting of this permit. �GANATURE 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