R 5986 (2) PERMIT5 9 8 6
APPLICATION FOR CITY OF CUPERTINO NUMBER R"
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT % (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
��/ -
IO3 /D / a RESIDENTIAL COMMERCIAL OTHER
OWNER'SR HAZARDOUS FIRE AREA
NAME /J�r I l� n / YES ❑ roof assembly streq rnd equired. Class A
NO ❑ Initial I.C.B.O:H
ADDRESS �7 Q EXISTING ROOF COVERING
PHONE •� Z,5/ NUMBER OF EXISTING COVERINGS L+
N ACTOR'S
J Q,5 C JZ��O.S' /� OD 1 //7 42
TO BE REMOVED ` TO 6E RETAINED
NAME
ADDRESS p TYPE OF ROOF COVERING
CITY B ZIP
Low Ga��s ''7 — EXISTING_
PHONE y4CC2g� ? '— �a BUILT-UP ROOF ❑
LICENSE
NUMBER .L ASPHALTSHINGLES
' LICE SED CONTRACTORS DECLARATION
1 hereby efflnm that I em licensed under provisions of Chapter 9(commencing with Section DOD SHAKES E]7000)of Division 3 of the Business and Professions Cotle,and my licenseIs
in
full force and
effect. /� Vv
License Class—k/'c+L4 y� Lic.Number �r / 7 HINGLES ❑
�T �QgH� lam) ❑
Date Contractor PROP
OWNER-BUILDER DECLARATION
I hereby affirm 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
conebuct,alter.improve.demolish,or repair any structure,prior to its Issuance,also requires the BUILT-UP ROOF P I f
eppllcent for such permit to file a signed statement that he Is licensed Pursue' to the provisions
of the Contractors License Lew(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he 18 exempt therefrom and the basis for the alleged ASPHALT SHINGLE$
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to 811(y1 I �rD
a civil penalty t not more than five hundred dollars($500).): �r�J1Q
L]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 sole(Sec.7044,Business entl Profes• ,1/,�
Bions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLE)Ilf Ur vyr-r;,fTrrl1rlstl
Improves thereon,and who does such work himself or through his own employees,provided that IJ
such improvements are not Intended or offered for sale.II,however,the building or Improvement .
to 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 sale.).
❑I,as owner of the property,em 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 incisors S
with a c m exempt
nrSe pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.s!A'
❑I em exempt under Sac. ,B 8 P.C.for this reason
Owner oats
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: gl 0 `
C]I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, BDlldln J
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this �7
permit I h v and �—( (� �.�( J3 Seismic
❑ have entl will maithe performance
Workers f the work
for Insurance,as required by Section Worker's U p,�
Me Labor Code,for the pertormance of the work for which this permit Is issued.My Worker's 7 O c/� Total /
Com ens" o Insurance terrier entl Il�Vu"�er era: ,/
Carrier /!21(n« PoutyNa� �sl79SU PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.O❑ ^ ^�r ' r `
(I certify that in the performance of the work for which this permit Is issued,I This section need not be completed If the permit Is for one hundred dollars($100)or less.)
,J VVVA
¢hell not employ
any person In any manner so as to became subject to the Workers'Compensation Laws of Cali- 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: 11,shat making this Certificate of Exemption,you should become Applicant subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP nt understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. Source regulations.
I cattily that I have read this application and state that the above Information is correct.)agree
to comply with all city and county ordinances and slate laws relating to building construction,and All roof an gs to be class��or better.
hereby authorize representatives of this city to enter upon the above-marnoned property for in.
ep(Wei
purposes.
(Wei agree to save,pe indemnify w entl keep harmlessway the City of Cupertino against liabilities,
ofthe gran caste and expenses white may In any way accrue against said City In consequents
• of the granting of this permit. SISI U RE OF APptT ANT 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