R 5930 (2) PERMIT R_ 5930
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3'2'28 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
1017.3 RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME COMMONS OF CU �FIst4o YES ❑ Irfoyf assembly srequirfeed.that ClaasA
N Initial I.C.B.O.#
ADDRESS— 101'35 EONIIIIIZE55 R. - EXISTING ROOF COVERING
PHONE (4c6) 39S- C1606 NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S /� 77
NAME L05 Cmxms Roont46 TO BE REMOVED I TO BE RETAINED
ADDRESSc TYPE OF ROOF COVERING
CITYaZIPJ111 SMITH AVE I Spill CIS11-7EXISTING
PHONE (go%) 359-1233 BUILT-UP ROOFLICENSE
❑
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby inion that em licensed antler Professions
loss of Chapter y(commencing with Section WOOD SHAKES.
7000)of Division 3 of the Business and Profe9slone Cade,and my license Is In lull force and
effect.
License Class C3q Lie.Number 495541, WOOD SHINGLES ❑
Dale Otis-04-95 Contractor Los 0ATd.S AcoFSNb 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 Profeslons 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 ss�� ❑
applicant for such permit to lila a signed statement that he Is licensed purauant to the provislons P A
of the Contractor's License Law(Chapter B(commencing with Section 7000)of Division 3 of the A
• 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 subject$the applicant to ,/�
e civil penalty of not more than five y employees
yeesdollars(h wag): WOOD$HAISu,.,t � � /�d/II
❑Las owner nth cture I not I tended oyeeered wages as(Sec.their Bole compensation,snd Prlll e. lgl r `I/�t[yo
the work,and the structure Is not Intended or,send for sale(Sea.7044,Business entl Proles-
alone Code:The Contractor's Licence Law dome not apply to an owner of property who builds orimproWOOD SHINGLES GULL
such Improveandments
are
who doessuchor workhimselffor for.If,through his own e building
or Improvement tyTyyy ❑
such Improve menta are not Intended the
offered for edea.ill however,the bantling o i Improvement
Is t he did
not ld bull thinor
provne e for purpose
see.Owner-builderwill have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve far purpose of sale.).
[11.as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Profession 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 contructogs)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date —
APPLICATION DATE VALUATION PERMI
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 Worker's Compensation, BUI(arlf��I
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this w
permit Is Issued. /A'�r
' Seismic
❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 of �(P -0� -98 I 00
the Labor Code,for the performance of the work for which this permit is issued.My Workers 1
Compensation Insurance carrier and Policy number ere: Total
Carrier AMMTCAN _%G1E[.TSor4 PailcyNo, SEQ DQW25'-O0 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) r Ias5
1 certify that in the performance of the work for which this permit Is Issued,I shale not employ
any person In any manner so as to become Subject to the Workers'Compern adon Laws of Cali. All roofs shall be inspected prior to anp roofinb laterlaftauklig
fornia. installed. If a roof is installed without first obtaining an
Data 01.-04'99 Applicant /�-Lia.... Dol inspection,I agree to remove all new materials for inspection.
of Exemou
subN�to the Workers'Compensation provisionICE TO APPLICANT: It,after makinls of thelcam Laborr Code,yolu must forthwliahcecome comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. Source regulations.
I certify that I have read this application and state 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 coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spetlon purposes. � -
(We)agree to save,Indemnity antl keep harmless the City of Cupertino against liabilities, -,(Agry) -coy-98
judgments,costs and expenses which may In any way accrue against said City In consequence
' of the granting of this permit. SIGNATURE OF APPLICANT DATE IN
PRE-INSPECTION: PLYWOOD: -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