R 5231 (2) PERMIT R_ 5231
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
r,>P_41
l RESIDENTIAL COMMERCIAL OTHER
OWNER'SHAZARD OUS FIRE AREA
M/ M ayK C 6 U " VES ❑ If yes—I understand that a Class A
NAME—__ �e1 assembly is required.
NO Initial I.C.B.O.11
ADDRESS
20305 CL,IFDeP4 WA [ EXISTING ROOF COVERING
p�� /
AONE `CO Z 6[7 NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S /
�res —s oTO BE REMOVED TO BE RETAINED
NAME 1 �'l VI/e
ADDRESS �V6� 1�/'��f_�Ir I n,J� CTI.(L TYPE OFROOF C�
CITUB ZIP(y�QO r r��W R l.F/� 1�. •�.J EXISTING
PHONE /fir _✓ Vy"1 2WO BUILT-UP ROOF ❑ �`
CENSE
NUMBER C3 01 6,57 3ag ASPHALT SHINGLES ❑ "/
LICENSED CONTRACTORS DECLARATION
hereby aaem that I em licensedunder provisions Chapter g(commencing withSection WOOD SHAKES
7000)of Division 3 0l the Business
and Prolesslone Code,and my license is In lull force and
affect' n at /nS WOOD SHINGLES ❑
License Class ✓3 1 Lic.Number ✓ �3,q 9
Date �(� (� Contractor Ne_*54AfT OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION (� PROPOSED P A B
1 hereby affirm that I am exempt from the Contractor's License Lew or ih ilow ng reason.
(Sec.7031.5,Business and Prolesslone Code: Any city or county which requires a permit to
conelrucl,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF q�90y 121996
applicant for such permit to file a Signed statement that he Is licensed pursuenl to the provisions
of the Contractor's License Law(Chapter g(commencing with Section 7000)of Division 3 of(he
. Business 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 Y OF UUFEYii lido
a civil penalty of not mora than five hundred dollars($500).):
❑1,as owner of the property,or my employees with wages as(heir sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles.
Ions Code:The Contractor's License Lew does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or.It,how his own employees,Improvement that ❑ �/_
such Improvements are not Intentletl or owner-builder
for edea. ill however,the building or ImprovementIs sold
not
or hIn
prove for purpose of
owner-bulltlerwill have the burden of provingthat hedid OTHER(SPECIFY)
not build or Improvo for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct STd��
me project(Sec.7044,Business and Professions Code:Th Contractors License Law does not PROVIDE I.C.B.O.REPORT NO. J
apply to an owner of property who bunds or Improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS❑I am exempt under Sec. ,B S P.C.for this reason
Owner Date APPLICATION DATE VALUATIO MIT 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 self-Insure for Workers Compensation, Building
r as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /' fI�
" permit Is have
and /� /' /( V d d Seismic
/ 50
havCentl will malthe performance
Worker's Compensation the work
Insurance,as required su Section 3700 of // /(`�'�
.the Labor Catla,for the pedormanca of the work for which This permit is Issuatl.My Workers `(
Compensattl1 Ilnaumnc(e�cerrlare�nttlPolicynumberere: Total
Carrier S{�tPc Kms-„ Policy No.133D PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 1.0 /
(This section need not be complatetl If the permit Is for dna hundred dollars($100))or lase.) �
1 certify that In the performance of the work for which this permit Is issued,I shall not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of Cell. All root^SPall be inspected prior to any roofing material b ing
fornia. installed. If a roof is installed without first obtaining an
Date. //—/3 1 Applicant IhNI '�/�� inspection,I agree to remove all new materials for inspection.
subject to theoWorrkeraCC mponsatlon provisions ofit, :Ing this ethteflcate f Labor Code,you mustuforthwlithbecome
omply Applicant understands and will comply with all non point
with such provisions or this permit shalgbe 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 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.
sP e) purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
(W
ofthe g granting of this permit.dgments,costs and expenses which may In any way accrue against cam Clty In consequence 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 r ini