R 5470OFFICE COPY
NUMBER R- 5470
APPLICATION FOR CITY OF CUPERTINO
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
780 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/t p�.�
1127. IN11fq n5orl f}V1E �JCJIA—
RESIDENTIAL 't COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
In
YES ❑ It yes — I understand that a Class A
NAME C eW -
roof assembly is required.
NO ❑ Initial I.C.B.O. p
ADDRESS 11122 IA/ilk V SCY1 AVf_i.
EXISTING ROOF COVERING
PHONE 0 p —Q
NUMBER OF EXISTING COVERINGS 1
TO BE REMOVED I TO BE RETAINED
CONTRACTOR'S
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NAME Q/ _ ]f'aiGl'iS OOCIYILi TY1C+
ADDRESS �r 1—
r112 SA14dC.79'L- C
TYPE OF ROOF COVERING
CITY & ZIP k U�U .. /gi l l
EXISTING
PHONE dB ;•' 4455
BUILT-UP ROOF ❑
bra••
1..1Cee6P-' Cr"
LICENSE
NUMBER p 1 9$`54o
ASPHALT SHINGLES ❑ ��
LICENSED CONYhACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8 (commencing with Section
WOOD SHAKES ❑
7000) of Division 3 of the Business and Professions Code, and my license Is In lull force and
effect
WOOD SHINGLES ❑
License ClaesC Lic. Number 513oO1
7/�ry8
_— J
OTHER (SPECIFY) Q• Cer+�waod
Date commcorAl AnQ9CV1& OFIYIa"t�-•
OWNER-SUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the following reason.
PROPOSED
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct, al ter, improve, demolish, or repair any structure, prior to Its Issuance, also requires the
BUILT-UP ROOF El
for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law (Chapter B (commenclng with Section 7000) of Division 3 of the
Business and Professions Code) or that he la exempt therefrom and the basis for the alleged
Calo+Cx
ASPHALT SHINGLES
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars ($500).1:
❑ 1, 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 $HINGLF_S El
thereon, and who does such work himself or through his own employees, provided that
such Improvements are not Intended or offered for sale. It, however, the bul[ding or Improvement
(a sold within one year of completion, the owner -builder will have the burden of that he did
W
proving
not build or Improve for of sale.).
OTHER ($PE IFY) n�11Q ❑
purpose
,S
❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Code: The Contractors Lmanea Lew noes not
nI
PROVIDE 140. ORT' \0 N1
apply to an owner of property who builds or improves thereon, and who contracts for such projects
ll
with a contractons) licensed pursuant to the Contractor's License Law.
((�r11t
❑ I am exempt under Sec. ,B 6 P. C. for this reason
PROVIDE MF�(iR. IN$YALLATION SPECS.
�` .�
Owner oats
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
/4 �%/
❑ I have and will maintain a Certificate of Consent to sell -Insure for Workers Compensation,
BUlldln f ` `/
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit II Issued.
tel have and will maintain Worker's Compensation Insurance,
.r
'
=(%,.�
g
seismic
as required by Section 3700 of
the Labor Code, for the performance of the work for which this permit Is Issued. My Worker's
�/
Compotion Insurance carrier end Policy number are:
Total
carrfo u6li�T✓dcxnndVPmicyNo. 1122R4<Y2
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 leas.)
1.0
'11
I certify that In the performance of the work for which this permit Is issued. I shall not employ
6yOs
All roofs shall be inspected prior to any roofing material being
any person In any manner so as to become subject to the Workers' Compensation Laws of call.
forma.
installed. If a roof is installed without first. obtaining an
' Date Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE APPLICANT; If. after makinof Exemou
subject to theOWorrkers' Compensation previsionis of thteflLabor Code, cate yolu must fo thwlithbecome 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 elate laws relating to building construction, and
All roof coverings to be classOr er.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection,purposes.
(We) agree to Indemnify keep
7
save, and harmless the City of Cuperdno against Ilebllltlae,
judgments, costs and expenses which may In any way accrue against said City In consequence
N E OF APPLICV DATE
of the granting of this permit.
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