R 5130 (2) PERMIT R_ 513 0
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (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 /
f
RESIDENTIAL - COMMERCIAL OTHER t
OWNER 1 / HAZARDOUS FIRE AREA
I E L E N L YES N If yes—I understand that a Class A
NAME roof assembly is required.
NO ❑ Initial I.C.B.O.M
ADORES EXISTING ROOF COVERING
r PHONE (409 ) 913- 8563 NUMBER OF EXISTING COVERINGS 2:/
CONTRACTOR'S
NAME DMVIVY LE E TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY&zIP 10476 5-i'61CLIrJG �30✓a; CUPERT1K6,C695a14
EXISTING
PHONE C40$)-253'I?�8 BUILT-UP ROOF ❑
LICENSE
NUMBER 464,116 - ASPHALT SHIN ES /� d
LICENSED CONTRACTORS DECLARATION j
I hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect. WOOD SHING S Elf
License Coleco Lip.Number 6 6499 6
Date �,;311hl Contractor DANNY LEE OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt tram the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Profession$Code: Any city or county which requires a permit to
construct,alter.Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law(Chapter g(commencing with Section 7000)of Division 3 of the
✓� Bualness and Professions 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 applicant to
a civil penalty of not more than five hundred dollars($500).):
❑1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure is not Intended or offered for Bela(Sec.7044,Business and Profes-
sionsCode:The Contractor's License Law does not apply to an owner of property who build$or WOOD SHINGLES
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 Improvemant
Is sold within one year of completion,the owner-builder.111 have the burden of proving that he did OTHER(SPECIFY) El
build or Improve for purpose of sale.).
❑I,as owner of the property,am 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 NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractors License Lew. PROVIDE MFG,R.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declaration: ..
❑1 have and will maintain a Certificate of Consent to ealf-Insure for Worker's Compensation, @ Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this (1 1QJgC l
permit is issued. fpT, S
❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 of �xGQ � J - Seismic
the Labor Code,for the performance of the work for which this permit is issued.My Worker's x� 't y�jOCYJ Total
Compensation(Insurance carrierandPolicy number are: OO V V,r� i v(/
Carder STATE Fr/iyD
Policy No.s��9'9� Onl��9y 00PERMITAUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE IN DO
(This section need not be completed It the permit Is for one hundred doll ar8($100)or lees,) cl 023 16f-4mo
+ I certify that In the performance of the work for which this permit is Issued,I shell not employ.
any parson In any manner so as,to become subject to the Workers'Compensatlon Laws of Cali. All roofs Shall be Inspected Prior to any rooting mal tial being
fornia. o -[ ,, O� installed. If a roof is installed without first obtaining an
Date '`'3 Applicant �%r-�'= =, inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,after making this Certificate of Exemption,you should become Applicant understands and will Comply with all non dint
subject to the Workers'Compensation provisions of the Labor Cotle.you must forthwith comply PP P Y P
with such provisions or this permit shall be deemed revoked. source regulations.
I certify that I have react this application and state that the above Information Is correct.I agree
to comply with all city and county ordinances and stale laws rotating to building 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. n
eD purposes.
(We)
(We)agrees save,expenses
and keep harmless the Clry ai Cupertino Ci epalnan IleDllen e,
tact menta,coats and permit, a which may in any way accrue against seltl City n consequence
of iRe granting Of this permit. SIGNATURE 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