R-5450 (2) PERT
APPLICATION FOR CITY of CUPERTINO NUMB ERR- 111 0
\ REROOF PERMIT INSPECTION DIVISION PERMIT WORKEXPIRATIS
N
(408)777-3228 PERMIT 80PIKES IF WORK IS NOT STARTED
WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
( 100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
732 Cl/1u4 RESIDENTIAL COMMERCIAL OTHER
OWNER'S ,pvHAZARDOUS FIRE AREA
V� G YES ❑ II as-I understand that a Class A
NAME roof assembly is required.
NO ❑ Initial I.C.B.O.k
ADDRESS .S9H as., EXISTING ROOF COVERING
PHONE
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S nn
NAME `-0 S G�-.7�05 KO a`//GG TO BE REMOVED TO BE RETAINED
ADDRESS DTYPE OF ROOF COVERING
CITYBZIP 1726 VS / t_s -
EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER ,3 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect.
G -37 4it?" � G WOOD SHINGLES ❑
License ClassLic.Number
/ LDS dl�6s /1aptC�„b OTHER(SPECIFY)
Data Contractor -
OWNER-BUILDER DECLARATION PROPOSED >
hereby affirm that em exempt from the Contractor's License Lew for the following meson. `�
(Sec.7031.5,Business and Professions or rep Code: Any ucityrs or county which requires a permit to
construct,alter,Improve,to file signed statement that
prior tope Issuance,alsorequlresine BUILT-UP ROOF
applicant for such parent a lila a signed statement that he Is licensedSection
pursuant to the provisions
el the Contractors License Lew(Chapter 9(commencing with Secllon 7000)of Division 3 0/the
Business and Professions Cotle)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
e civil penalty a not more than five my employees
dollars(h wag): �
❑I,k, owner structure
I property,or tended oyeeeredfwages as(Sec.their sole compensation,sand
Prlll da WOOD SHAKES p�
the work,and the structure Is not Intended or offered for sale(Sew owner
of Business antl Profen- P
Improsionsves
Code:The Contractor's License Low does not or through
own employers,who builds orrovidethat WOOD SHINGLES J
Improves thereon,and who dose such work himself or mrouph his own employees,provided that pv
such Improvements are not Intended or offered for sale.If,however,the building or Improvement J;yl'xl
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) t-t�
not build or Improve for purpose of sale.).
❑I,as owner of Na property,am exclusively contracting with licensed contractors to construct
the project(Sec.7069.Business and Professions Code:The Contractors License Low 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 contractoge)Incensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
C]I am exempt under Sec. ,B&P.C.for this reason
Owner Dere
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to sell-Insure tar Workers Compensation, rL�/ BUlldln O
as provided for by section 3700 o1 the Labor Code,for the performance of the work for which this _23-9 g
permit Is Issued. Q 1 /�
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 o1sj e0 Seismic
the Labor Code,for the performance of the work for which this permit IS Issued.My Worker's
Compensation Insurance carrier and Policy number are: Total
Carrier_ G ��d�S� PoucyNo. eg.97/&JzsS — PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 el O n , C2
(This section need not be completed If the permit Is for one hundred dollars($100)or lase.)
1 certify that In the performance of the work for which this permit Is issued,I shell not employ
any person In any manner so as to become subject to the workers'compansadon Laws of Can. All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Data/'J•1L 9 Applicant inspection,I agree to remove all new materials for inspection.
subject NOTICE the Workers'Compensation proviafter sionis of the Lahorrtificate e Code,Exemption,
must fothwidthbecome
comply Applicant understands and will comply with all non point
with such provisions or this permit shell be doomed revoked. source regulations.
1 certify that I have read this application and state that the above Information Is correct.I agree
to comply with all cls,and county ordinances and state laws relating 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 properly for In.
spection purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities, /O-2•-.9
- 7
judgments,coats and expenses which may In any way accrue against said City Inconsequence
oI the granting of this permit. SIGNATURE OF A LI A T 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY