R-5145 (2) PERMIT R_ 514 5
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
\
BUILDING
ADDRESS
I//WzJ v /. L:;SC fit
RESIDENTli COMMERCIAL OTHER
OWNERS / AZARDOUS FIRE AREA
iC.� \ //1 4/S YES ❑ If yes—I understand that a Class A
NAME—C.-. V 1`� reef assembly is required.
/ �j"ter`- NO Initial I.C.B.O.B
ADDRESS /MZs7 C2.�sC CW T" " EXISTING ROOF COVERING
/� W
PHONE 2 W17? NUMBER OF EXISTING COVERINGS II
CONTRACTQR'Sr�� �.� NI
NAME ��``IIFF�N// � -� M TO BE REMOVED TO BE RETAINED
ADDRESS 7).0x Zc f/6 f� c���r,/ TYPE OF ROOF COVERING
clTvszlP n O J7 EXISTING
PHONE ` rt 47 BUILT-UP ROOF ❑
i LICENSE /
NUMBER J J ASPHALT SHINGLES ❑
�O
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
ffe
ect, WOOD SHINGLES
License Class c_39 Uc.Number q)(0 S3
Date —oZ 9_1y Contractor Q- -�Q/ll. OTHER(SPECIFY)
OWNER-BUILDER DECLARATION C
I hereby affirm that I am exempt from the Contractor's License Law for the following reason. PROPOSED >Z-
(Sec.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,altar,Improve,demolish,or repair any structure,prior 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 Contractors License Law(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
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars(s500).): OD SHAKES I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
WO
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Prefer.
Ions Code: The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES El
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
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 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 contractors)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: I D
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, (/ Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this p (� Q
per/nJtIs issued. VAAf 2,9 t % / U�/� Seismic
j�lI have end will maintain Workers Compensation Insurance,as required by Section 3700 of ( 0V Total/"T V(W
.Aabor Code,for the performance of the work for which this permit Is Issued.My Workers fry h V Total
ompans:)ii!nsuranceLLcerrler antl�jPo�licy number ere: 6, (J /�
Carrith z `^ �U Policy No.�/_���N�� PERUfl-THORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 r�•x
(This section need not be completed If the permit is for one hundred dollars($100)or less.) L
Ct
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 the Workers'Compensation Laws of Cell- All roofs shall be inspected prior to any rooting material eing
forma. installed. If a root is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE ecome
subject to the OWor ereCCompensation provisions ofANT: It,after making this ethe lL borcate nCode,Exemption,lu must should
comply Applicant understands and will comply with all non point
with such provisions or this permit shalQbe deemed revoked. - source regulations.
I certify that I have read this application and state that the above information Is correct.I agree
to amply with all city and county ordinances and state laws relating to building construction,and All roof overings to be C"or better.
herby authorize representatives of this city to enter upon the above-mentioned property for In- /n
epe) purposes.
(W �s . �j �• 7 qL�s
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City In consequence
of me 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