R 5796 (2) . APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5796 '
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
190 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS �[ 's n
A'JGyC£,-j /'� 44 ry RESIDENTIAL COMMERCIAL OTHER
—
OWNERS HAZARDOUS FIRE AREA
NAME w�7 d!ONS GG fi Li���ii✓O VES ❑ If yes s I undeassembly
i reqand that. Class A
root assembly is required.
NO ❑ Initial I.C.B.O.a
ADDRESS EXISTING ROOF COVERING
PHONE 3 ��— �o C NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
�x�/ TO BE REMOVED TO BE RETAINED
NAME - - '�S ✓-R 7 s /ZGe:iooli
ADDRESS IJ �� n 2 C.
�s��, e4 TYPE OF ROOF COVERING
ry
ClazIP 7_0 _ EXISTING
PHONE 3S �— /23� BUILT-UP ROOF. ❑
LICENSE ❑
NUMBER 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 lull force and
effect.
ptS ❑
'License Class C '3 / Lie.Number�qJ .� � � WOOD SHINGLES
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PpOPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason. Q
(Sac.7031.5,Business and Professions Code: Any city or county which requires a permit to p
construct,alter,improve,demolish,or repair any structure,prior to Its issuance,also requires theBUILT-UP ROOF WLrJI ro
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions Q
. of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the O
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
a civll penalty of not more than five hundred dollars($500).): r C .
as
❑l,as owner of the property,or my employees with wages as their note compensation,will do WOOD SHAKES (
the work,and the structure Is not Intended or offered for sale(Sac.7044,Business and Profes. V J1
stone Code:The Contractor.License Lew does not apply to an owner of property who builds or WOOD SHINGLES
G\� v
improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.If,however,the building or Improvement /S Z,
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO. L. ,(,
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(e)licensed pursuant to the Contractor's License Lew, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B a P.C.for this reason
Owner Dale
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
` ❑1 have and will maintain a Certificate of Consent to self-usure for Workers Compensation, Building /y/11
"1,70
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit01a Issued. Seismic t a»
❑I have andCode will maintain Worker's Compensation the wokfor Insurance,as permit is I su Section 37oe s
the Labor tion I for the performance of the work for which this permit is Issued.My Workers Q 4r,0,:j
Compensation Insurance carrier and Policy number are: Total
Carrier AN$E=CNA PA=Xbr Policy No. SBR 05W95-00 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NCO
(This section need not be completed If the permit Is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit is issued,1 shall not employ •••...///
any person In any manner so as to became subject to the Workers'Compensation Laws of Cell- All roofs shall be Inspected pr any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date 5-7-9-9$ Applicant A.usv+e '*� inspection,I agree to remove all new materials for inspection.
subject t.the T CE TO
orms Compensaton making
re isionls oche Labor code you moatfonnwiihbcomplyy Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked, Source regulations.
I certify that l have read this application and state that the above Information is correct.l agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof cover'ngs to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes. O
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
• judgments,costs and expenses Which may In any way accrue against said City ,.caa90quence
of the granting of this permit. 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 COPY