R 5849 (2) APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5849
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1B DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS '
C� (24ni fo O UIS I(ye RESIDENTIAL COMMERCIAL OTHER
OWNER'S yy HAZARDOUS FIRE AREA
NAME M,2 PChe MAS I CUN N JI� YES ❑ reaf as l mbly is reqand that a Cl2aS A
roof assembly is required.
If - NO ❑ Initial LC.B.O.If
ADDRESS /1413 ? P7AoPR//e-S 13 R, EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S /
NAME /�1 yr '
OR i1�'S 1'n✓tG RDUr ' TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY a ZIP _ I[o O S 1KwWia1(4 no 611 S417 12Q �cl d
/ p Q c lly EXISTING
PHONE �NoB) `/ - l7 � 0 BUILT-UP ROOF ❑
LICENSE ' 2170(10 ASPHALT SHINGLES ❑
NUMBER Ci v/
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensedunder provisions of Chapter 8(commencing with Section WOOD SHAKES El7000)of Division 3 of the Business
antl Professions Coda,and my license Is In lull force and /
effect.
C_3 / 7 Z D)� WOOD SHINGLES ❑
Cleanse Clese p Lic.Number l7
Date L4 ?—'2 -90 Contractor C0k30ee54_C`V1G11WC' OTHER(SPECIFY)��� Er
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to -
construct,elter,Improve,demolish.or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF ❑
eppllcent for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor'"License Law(Chapter 8(commencing with Section 7000)of Division 3 of the
Business and Profosslons Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the epplicantto pp9
a civil penalty of not more than five hundred dollars($5001.): ^
M
❑I,as owner of the property,or my employees with wages as their able compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles. ANSr
sionsCode:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLESePRI
D
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.If,however,the building or Improvement U
Is coed within one year of completion,the owner-budder will have the burden of proving that he did OTHER(SPECIFY)2I
not build or improve for purpose of sale.). Y V
❑I,as owner of the property,am 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 Wilds or Improves thereon,and who contracts for such projects
with a contractor(e)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.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:
04have and will maintain a Certificate of Consent to self-insure for Workers Compensation, 'A O Building OO
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 7
permit Is Issued. 22 / Seismic S�
❑I have and will the performance
Workers Compensation Insurance,as required su Section Worker's
_
the Leber Code,for the performance fol the work for which this permit Is Iesuetl.My Workers Q�-7 S_-Qj
'Carrier etlon Insurance�errler Policy number are: p C Total
Carrier 51 q'+-� (-u c'Y:� Policy No. 14,yon 7 - L7 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed 1f the permh is for one hundred dollars($100)or lass.) •--�
I certify that in the performance of the work for which this permit Is Issued,I shall not employ
7 1
any person in any manner so as to become subject to the workers•campenaeuan Lawa of Cau- All roofs shall be inspected prior to any roofing material being
fomis.4/ > L b installed. If a roof is installed without first obtaining an
Date M��Z"7 a Applicant � �- inspection,I agree to remove all new materials for inspection.
NOT CE Applicant
TO APPLICANT: If,after making this Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the tabor Code,you must forthwith comply PP•leant understands and will comply with all non point
with such provisions or this permit shaNbe 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 bulldIng construction,and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
sp(we) purposes. ^/ //_�2_��
(Wal"gree to save,indemnify and keep harmless the City of Cupertino epaIII Ilabhlaea. �( s^/
jutlgmente,costa and expenses which may in any way accrue against said City in consequence SIGNATURE OF APPLICANT
of the granting of this permit. 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