R 5870 (2) PERMIT R_ 5870
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT - (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS ,/
Io I C 1 2 Q_A�Q l '>a- CP. J)(U RESIDENTIAL COMMERCIAL OTHER
OWNER''S HAZARDOUS FIRE AREA
NAMES.OMmo"JV r �"� .SfIQ � ' YES ❑ If yes—I understand theta Class
�/ A V(F Q/Ll roof assembly is required.
A)-
' NO Initial I.C.B.O.41
ADDRESS 2-9:57A)-- ,"ItrQ It T/ST e - EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
wnA l SSAAJC�, ��(p �L TO BE REMOVED S TO BE RETAINED
NAME O _ ,
ADDRESS 2.Zil Litic M .4fle, SJ ci s-I ZS TYPE OF ROOF COVERING -
CITY&ZIP .J
EXISTING
PHONE (408 Nit t{4$- oGq} BUILT-UP ROOF CAP
LICENSE
NUMBER 22 / ASPHALT SHINGLES ❑
SSG �rJ 0
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter S(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Busnoss and Professions Code,and my license Is In full force and
effect.
5s4 X36 WOOD SHINGLES Elfi. License Claes Lic.Number
Date Contractor 9+J?M.H55l_ �F6 OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby allirm that I am exempt from the Contractor's License Lew for the following reason,
(Sec.7031.5,Business and Professions Code; Any city or county which requires a permit to OM sem.—ZPL V5
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UPP(gDO f
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter B(commencing with Section 7000)of Division 3 of the Sri ❑ N�'e`- P
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHIP)
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to p (a� N
e civil,enalty as owe not more than fivehundred empl dollaemployees
with
wage P
❑Las owner stature Is not
tended oyeaered wages as their.7sole compensation,sanPrilf s. WOOD�H ES NU
the work,and me structure le not Intentletl or s not for sale(Sea owner
of Redness and Pms or p'yy I VUt"[h I U
slops Code:The Contractors es such Law dome not apply to an owner of property who builds or WOOU)JH114 ALES•
suchImprImprovements
thereon,and who does deco work himself or through his awn employees,provided that
doth Improvemanta ere 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 dale.).
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT N0.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with aontractogel licensed pursuant to the Convectors License Law. PROVIDE Ill INSTALLATION SPECS.
El am exempt under See. ,B 6 R 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:
❑I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, Building as provided for by Section 3700 of the Labor Code,for the performance of the work for which this (� g
permit is Issued,
le 9 Seismic
❑ have and w111 the performance
Worker's Compensation work ton Insurance,as required Is
Issued.
Section Workers s / C,1 1
the Lobar Cotle,for the performance of the work for which this permit la lseuetl.My Workers
Compensation Insurance carrier and Polley number are: Total
Carrier 5rAre- A;fJNb Poticy No. 4 P 10YZ;V3 PERMIT AUTHORIZATION DAT
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NA.pLaw
(This section need not be completed If the permit Is for one hundred dollars(5100)or leas.)
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 become subject to the Workers'Compensation Laws of Cell- All roofs Shal a Inspected prior to any roofing material being
torula. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOT CE TO APPLICANP. ii snsiLEExemption,
1uubecome
subject Io t Workers'Compensatprovisions of the C 0u mstfqthwihcomply Applicant understands and will comply with all non point
with such pro0alond 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 ro coverings o 4e C, . Getter
hereby authorize representatives of this city to enter upon the above-montioned property for In.spectlon purposes. Z V
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said Clty In onsequance NATURE OF APPLICANT ATE
of the greeting of Ihjs 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