R 5521 (2) APPLICATION FOR CITY OF CUPERTINO
rPE sER R- 5 5 21
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408)777-.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
ISSUANCE WITHIN 150 DAYS OF PERMIT O
WI DAYS FROM LAST CALLED CION,,
BUILDING ADDRESS
S9o� �o-L4N��c Ro,vo
RESIDENTIAL COMMERCIAL OTHER
OWNER'S /1/f O, "� �� / HAZARDOUS FIRE AREA
NAME GJ�AR��S (J �JL��TCnSCA/ VES ❑, Ryes—embly itaequire . ClaesA
roof assembly undo Is required. .
NO ❑ inifil I.C.B.O.#
ADDRESS �� /v� �Ot.tt.J[�sF� Rcl4D EXISTING ROOF COVERING
' PHONE 02sa — /34)-7 NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
./G /a?� TO BE REMOVED TO BE RETAINED
� ry
NAME ff/L [L071/
ADDRESS A0.{ G� [ Q TYPE OF ROOF COVERING
CITY s ZIP
�—�S EXISTING .
e PHONE 7 7--b 7ft BUILT-UP ROOF ❑
LICENSE .❑
NUMBER d C3 ASPHALT SHINGLES
LICENSED CONTRACItRS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 5(comment' Po
g with Section WOOD SHAKES p
7000)of Division 3 of the Business and Professions Cotle,a my license le full force and I D
enact. AA WOOD SHINGLES ❑
License Close Llc.Number
Date / Contractor OTHER(SPECIFY)
tOWNERBUILDER CLARATIO PROPOSE OF l:W!'EHT9N0
1 In affirm Thal em exempt from me Contmctofe Licensr. h. lowing reason.(Sec.7031.5,Business entl Professions Cotle: Any city or coueea permt toconatruc6 alter,Improve,demolish,or repair any structure,prioriso requlree the BUILT-UP ROOFapplicant for such permit to Ills eelgned etetemenl that he le litethe provisions
• of the Contractor's License Lew(Chapter 5(commencing with Section 7000)of Division 3 of the
"Business and Professions Code)or that he Is exempt therefromand 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).):
Cl 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 SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ❑ (/ y
such improvements are not Intended or offered for sale.If,however,the building or Improvement JC
Is sold within one year of completion,the owner-bullder 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 Contractors License Lew 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 eontmctorts)licensed pursuant to the Contractor's License Lew, PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,B&P.C.for this reason
z Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the fallowing declaration:
❑I have and will maintain a Certificate of Consent to aeibinsure for Worker's Compensation, Building as provided for by Section 3700 of the Labor Code,for the performance of the work for which this (�/y g
r p�rm�l h v and goo
$elSfillC
/BI have entl will themaintainrt Worker's Compensation the work
for whichInsurance,this permit Is Is by d.My
Worker's
of { o
e L or Cotle,for the performance of the work for which tM1ls permit la laeuetl.My Worker's / 4
Compere Ion lnnsu/r�anncce-carrier
and PPoliiccyl number are: Total
Carrie �s/uSS�S� �aTx++{—` Policy No.317-621^a/ TAUTHORIZATI DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE .C.0 /
(This section need not be completed It the permit le r one hundred tl011era 100)or lees.) A
certify that in the performance of the work for whit Ihla ermit I tl, nail not em
any person In any manner so as to become subj to a ker ' om a Laws a k. All roofs II be inspected prior to any roofing material being
lornie. 7 9 install9d. If a roof is installed without first obtaining an
Date " • Applicant ins tion,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of ou should beco
subject to the Workers'Compensation provisions of the Labor d you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shalgbe deemed revoked. Source regu Ions.
Icertity shall have read this application and elate that the ova formation Is cOrrect.l agree
to comply with all city and county ordinances and state laws to t to building comlruction,and All rO f "orbetter.
hereby authorize representatives of this city to enter upon the ova-mentioned
an for In.
spection purposes.
jWe)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costa and expenses which may In any way accrue against said City In consequence
• of the granting of this permit. /_&GNAr E 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