R 5886 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO . NUMBER R- 5886
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 100 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
(CL exAAA RESIDENTIAL COMMERCIAL OTHER
o E s^' ►^\ �/ HAZARDOUS FIRE AREA
NAME 1�a If T� ✓1 le �L YES ❑ If yes—assembly
its andreq fired.hat Class A
roof assembly is required.
NO ❑ � Initial I.C.B.O.k
ADDRESS 5 aeV-% Q— EXISTING ROOF COVERING
PHONE C.�Jr NUMBER OF EXISTING COVERINGS /
CONTRA TOR'S
NX TO BE RETAINED
AME TO BE REMOVED
ADDRESS n� �� I ,_(, /l�h/> TYPE OF ROOF COVERING
CITY&2IP ` of ` l?LIAIQ,�,"1• IUI�
EXISTING
PHONE
9'9 BUILT-UP ROOF ❑
NCENBERSE ASPHALT SHINGLES �► >��
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
7000)of DIVISIon 3 of the Business and Professions Code,and my license Is In full force and
effect.
/► 2 C] 401 yT '94� WOOD SHINGLES E]License Cleve�J— Llc.Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Lew for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,improve,demolish,or repair any structure,pdor 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 Lew(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
toexemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to r�
a civil penalty of not more than five hundred dollars($500).): P A 0 LJ
01,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES IIJJ
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 MAY 1 `i111J,D
Improves thereon,and who does such work himself or through his own employees,provided that n
such Improvements are not Intended or offered for Sale,11,however,the building or Improvement
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 safe.). CI I Y U VV f t un V
❑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 Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under See. ,B It P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-insure lot Workers Compensation, n Buildin ww
as provided for by Section 3700 of the Labor Code,for the performance of the work for winch this s\/' 41x7 g V
permit Is leaned. J "/�- LY Seismic ,(n0
❑I have and will the performance
Worker's Compensation the work
for Insurance,as required u Section Worker's'of s
the Labor Code,for the performance of the work far which lila permit Is Issued.My Worker's ['�/O 0 Total l/77. 60
Com//99qyJ)atl1loMMn lnaurenca carrier an�°°//��ollc umber ere: IIn .J
C arrlel"7..[lJ_��l nly,U xYJ7] o/�1cy No.45 �2.O51LW PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(This section need not be completed If the permit le for one hundred dollars($100)or less.) r
I certify that In the performance of the work for which this permit is issued.I shall not employ J
any person In any manner so as to become subject to the Workers'Compensation Laws of Call- A oofs shall be inspe;t prior to any roc ing material being
forma. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non slot
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP P Y P
with such provisions or this permit Shell be deemed revoked. source regulations.
I calmly that I have read this application and State that the above Information Is correct.I agree
to comply with all cityand county ordinances and state laws relating to building construction,and All roof rings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgment$,coats and expenses which may In any way accrue against said City In consequence
' at the granting of In)*psrmn. SIGNATURE OF AP ICANT 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