R 5395 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5395
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
,.' WITHIN 100 DAYS OF PERMIT ISSUANCE OR
180 DAYS LAST CALLED INSPECTION.
BUILDING ADDRESS
cWaa 55. oa,c� RESIDENTIAL COMMERCIAL OTHER
owNER's 1 J HAZARDOUS FIRE AREA
1 j111J4 V e-D x -De CeF./J/ VES If yes—motes assembly
starts iced. Class
NAMES/,�6^^..IM w I T Y�11✓uA� VVV(,(,/L �,�'G(-( c»"YII, LLIII roof assembly is rid that
ADDRESsaaa� - RW J NO ROInitiaOF
LC.B.O.N
EXISTING ROOF COVERING
PHONE b NUMBER OF EXISTING COVERINGS
CONTR R'S
UrDWYL ) Parte TO BE REMOVED TO BE RETAINED
NAME
ADDRESS CaI r I /1 „ .• _� I „ _ , TYPE OF ROOF COVERING
CITU 8 ZIP `� l.J LLJCJ Lf�.Z(�Y./
3(oq
PHONE EXISTING
BUILT-UP ROOF ❑
LICENSE cam" ASPHALT SHINGLES
NUMBER ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)or Division 3 of the Business end.Profeselons Code,and my license is In lull force and
efface WOOD SHINGLES ❑
License Cl e Llc.Number -
/�"J11 1IQbVOTHER(SPECIFY) ❑
Date /`� 0 Contract
NER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Conbators License Law for he following reason.
IS
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 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 Proviofessions f Code)or that he le exempt antforam entl the heals for the applicant
to ASPHALT SHINGLES OCTn ❑
exempss and rotes ions Code)Section 7031,5 that he
ys a applicant the efr a permit he basis
the the alleged 4/ '(
a civil penalty of not more than five hundred dollars($500).): /9
❑1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES �Ee�
the work,and the structure Is not Intended or offered for sale(See.7046,Business and Profes. Call,
sions Code:The Contractor's License Lew does not apply to an owner of property who builds or (Jh
improves VU!-
thereon,and who does such work himself or through his Own employees,provided that WOOD SHINGLES
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 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.
C] PROVIDE MFGR. INSTALLATION SPECS.
I am exempt under Sec. ,B a P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATIONDECLARATIONAPPLICATION DATEI VALUATION I PERMIT FEE
1 hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Cartlficah of Consent to self-insure for Worker's Compensation, Building
eavitl is farby Section 3]0001 the Labor Coda,for the performance Of the work for which this ! 1�� g
permmissued. `I/l,
ave and will maintain Worker's Compensation Insurance,as required by Section 3700 of 4 Seismic
lh or Code,for the performance of the work for which this permit Is Issued.My Workers /7
Comports on}n/sur nce carand Policy myMbef are: / - Total
Carrier S..G/(6G Policl( PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N,C.�
(This section need not be completed if the permit Is for one hundred dollars($100)ar less.)
I certify that in the performance of the work for which this permit Is Issued,1 shell not am toy -
any peso In any anner so as to become subject to the Workers'Compensation Laws of�a1- All roofs shall be inspected prior to any roofing material being
a`niq installed. If a roof is installed without first obtaining an
Date! Applica inspection,I agree to remove all new materials for inspection.
NOT d become
subject to the Workero'Campena tion proTO PLIC NT: If,after me ivistones 0 thterlc oro Cada,Exemption,
mustforthwlith comply Applicant understands and will c ply with all non point
with such provisions or this permit shall). tleemetl two ad. Source regulations.
I certify that I have read this application and state that the above Information Is correctI agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof Brings to e S O Iter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments.costa and expenses which may In any way accrue against said City In consequence
' of the granting of his permit. SIG A U OF APPLICAN 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 - ,