R 5917 (2) PERMIT R_ 5917
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)7 -3228 PERMIT EXPIRES IF WORK IS NOT STARTED
' WITHIN 1110 DAYS OF PERMIT ISSUANCE OR
190 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
UU S S RESIDENTIAL COMMERCIAL OTHER
OWNER' /Y� HAZARDOUS FIRE AREA
NAME��S �0 S 1�//,/o�r�l✓l� lO , YES ❑ roofIt as Imbly is understand ClassA
roof assembly is required.
11 NO ❑ Initial I.C.B.O.k
ADDRESS 7�7 h/ I/G'{'S t 7 V /�� 16" EXISTING ROOF/COVERING
GCaS o s ` �v -3 v NUMBER OF EXISTING COVERINGS
PHONE el
CONTRACTOR'S �/
NAME Las GQ f O S �O O Ta Q TO BE REMOVED / TO 8E RETAINED
ADDRESS /Ya. ,Q _ I �Z/_ �OS 6k'j"p.S TYpE OF ROOF COVERING
CIN 8 ZIP [y'�U .fUnX \rr
9Sa�) EXISTING
PHONE Ol? ,358'-1233 BUILT-UP ROOF ❑ '-`-` —
CENSE
NUMBER (/ ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION 972
1 hereby iaffirmnion that em si nes under provisions of Chapter 9(commenting with Section 'WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is In lull force and
effect,
Lqqq y/ 3 ❑
License Class� Lic.Number J WOOD SHINGLES ISD
Date Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law 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,prior to Its Issuance,also requires the BUILT-UP ROOF El
for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Lew(Chapter 9(commencing with Section 7000)of Division 3 of the• ASPHALT SHINGLES ❑Business and Professions Code)or that he le exempt therefrom and the basis for the alleged
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than live hundred dollars($500).): /
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES /➢`4'-
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles-
, slons Cotle:The Contractors License Lew does not apply to an owner of property who bullds or WOOD SHINGLES
Improves thereon,and who tloee such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) .❑
not 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 Contractor's License Lew does not PROVIDE I.C.B.O. REPORT NO.
apply to c n owner of property who butdr,t or Improves thereon,and who contracts Int such projects ')Q
with coniexemt licensed pursuant to the contractor's License Lew. Ca a� PROVIDE MFGR.INSTALLATION SPECS.
If
❑I em exempt under Sec, ,B 8 P.C.for hTs r�9oh '�r
OwnerWORKRS Date
DECLARATION
TIO 1I�1 PLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the(following declaration: JUN 10
Ell have end will maintain a Certlllcah of Consent to self-insure for Worker's Compensation, , ^o
as provided for by Section 3700 of the Labor Code,for the performance of he rp farwhlch�(ilA•Crt Ilv}U Building
permit Is Issued. (X1(1 UI tt —(e, //4�� $ p
❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 of y/Q eISn11C /•
,the Labor Code,for the performance of the workforwhich this permit Is Issued.My Workers f ee
Compete(,otn InsurancecPgpmbSBR z/ S Total
Carrier l� Policy No. L
PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C. �-y/�/,�
(This section need not be completed If the permit is for one hundred dollars($100)or less.) C �+ 6-11-1726
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 to become subject to he Workers•Compensaun Laws of Cell- All roofs shall be inspected 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 TO APPLICANT: If,alter making this Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Code.you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shelrtbe deemed revoked. Source regulations.
I certify that I have read this application and stele that the above Information is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof cngsto beclass"oorbetter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
eDpurposes.
(We)
(We)agrees save,expenses
and keep harmless was Ice City of Cupertino y Inagainstcon liabilities,
judgments,costa and expenses which may In any way accrue against ealtl City Inconsequence
of iM1e granting of this permit. SI ATURE OF APP CANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
q
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