R 5039 (2) APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5039
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 130 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
10z'1 ) CoL,gY A.1>=
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
—T /, YES E] If yes—I understand that a Class A ,
NAME J 0 a'-F N I� 055 mof assembly is required.
NO ❑ Initial I.C.B.O.41
ADDRESS (O47 ) Got_f3 t ��C EXISTING ROOF COVERING
PHONE 25-7-7-0-7(111, NUMBER OF EXISTING COVERINGS I µeq'-ti"r 5 y41Cta
CONTRACTOR'S
NAME '�`�� Int-1aSE �,rll�ufr-fEQS £ Fr�� TO BE REMOVED ) - TO BE RETAINED
r
ADDRESS TYPE OF ROOF COVERING
CITY a ZIP 315 CL.sm<e LH. 1AAliiczr..w 41t. 95037
r \ EXISTING
PHONE`9� )��q—��40 BUILT-UP ROOF
LICEN
NUMBER 576(.8-73 ASPHALT SHINGLES El
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 3(commencing with Section WOOD SHAKES
7000)of Division 3 01 he Business and Professions Code,and my license is In lull force and
effect. WOOD SHINGLES El Class �' Lie.Number � `
DaContract
® q �„ OTHER(SPECIFY) ❑
le � s
OWNER-BUILDER DECLARATION PROPOSED
1 hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sac.7031.5,Business and Professions 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 sta ement that he Is licensed pursuant to the provlalons
of the Contractors License Law(Chapter 3 mma QIng with Section 7000)of Division 3 of the
Business and Professions Code)or thel he I ax 1,therefrnm and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 yra appJlcant for a permit subjects the applicant to
a civil penalty of not more than five Vn it dot (,500).):
❑I,as ownerol the propsmy6 oy wages as their sola compensation,will do WOOD SHAKES ❑
the work,and the structure sof Intan ad for sale(Sec.7044,Business and Profes-
sions Code:The Contract can a not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and Bods Imsell or through his own employees,provided that ❑
such Improvements aro Ant "a ad for sale.If,however,the building or Improvement
Is said within one year of oil ,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve I urpo 1 sale.).
❑tasowneroft pro ty,am exclusively contracting with licensed contractors to construct
the project(Sec.7044;,j mess and Professions Code:The Contractor's 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(e)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sac. ,B$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:
E]I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, BUIIdin Cb
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this ''') l, g q
permit is Issued, !/)9 S,QV / -\
El have and will maintain Workers Compensation Insurance,as required by Section 3700 of 6, s(ypA� Seismic
.the Labor Code,for the performance of the work for which this permit is Issued.My Workers / •
Compensation Insurance carrier and Policy number are: - Total
Carrier/='aK' I�L!W!7 Policy No. 137?i251—913 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed It the permit Is for one hundred dollars($100)or less.) 9� i1
,a I certify that in the performance of the work for which this permit is Issued,I shall not employ
any person in any manner so as 10 become subject to he Workers'Compensation Laws of Ce11- All roots.shall be ected prior to any roofing material being
fornia, installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE APPLICANT:
it,after
making
itlflluushould
become
suthacct to the WWorkers'Compensation previsions ofheLaborr Code,you mstforthwithcomply Applicant understands and will comply with all non point
with such provisions or this permit shalGbe deemed revoked, source regulations.
I certify that I have read this application and state that he above Information is correctI agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverin s to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes. ' p
(We)agree to save,indemnity and keep harmless the Cly of Cupertino against liabilities, H'$ $ I L
ofthe granting of this percosts and mit es which may In any way accrue against said Cly In consequence SIGNATURE OFAPP C NT DATE
PRE-INSPECTION: PLYWOOD: IN-PROG ESS:
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
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