R 5167 (2) PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5167
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS 7
77.5-3, `/ 0. 4-, I Q� �—� RESIDENTIAL_ COMMERCIAL OTHER
'OWNER'S HAZARDOUS FIRE AREA
/ YES ❑ It yes-I understand that a Class A
NAMEroof assembly is required.
NO ❑ Initial I.C.B.O.W
t
ADDRESS7-
EXISTING ROOF COVERING
PHONE
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED Z TO BE RETAINED
NAME lu
ADDRESS / / n TYPE OF ROOF COVERING.
CITY&ZIP J t EXISTING i
PHONE 3 Ck� ^ �y a() BUILT-UP ROOF
LICENSE
NUMBER 95 7 3 '? ASPHALTSHINGLES /l7
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license is In full force and
effect. WOOD SHINGLES
License Cis LIC.N.m 9 P A I V
Date Contracto OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATIONPROPOSED OCT 41996
1 hereby affirm that I am exempt from the Contractor's License Law Ior 1 a 1.11b ng reason.
(Sec.7031.5,Business and Professions Code; Any city or county which requires a permit to
consVuct,alter,Improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF CIII vi vvl'"nu1VV
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 6(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($500).):
01,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profea-
alone Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intendedn,the
offeredwner for lade. ill however,the en of pr or ImprovementIs sold
not build thinor
year of for purpose
sthe ownerbuiltlerwlll have the burden of proving that he did OTHER(SPECIFY)
not bulitl or Improve far purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct 7
the project(Sec.7044,Business and Professions Code:The Contractor's License Lew does not PROVIDE I.C.B.O.REPORT NO. 13�a54
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 Law. PROVIDE MFGR.INSTALLATION SPECS.
1 em exempt under Sec. ,B 8 P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration;
I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, p0 Building
as Provided for by Section 3700 of the Labor Coda,for the performance of the work for which this
Perm)Isissued. �I� �/z S9 Seismic
have and will the performance
Worker's Compensation the work
kfor Insurance,pe required by Section 3700's
1 La r Code,Mr the padormence o11he work for which this permit Is leauetl.My Worker's
I.Rumpensatlon L anfj ca:rri�{er/ten-d P�allcy number are: qq qq y`[,A' e/ Total
Carrier _- --" • Policy No.4%3F/ �Tb PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit Is for one hundred dollars($100)or less.)
1 certify that In the performance of the work for which this permit Is Issued,f shall not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected prior to any roofing material being
fornia.
installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICsubject to Eh wAPPLICANT:' pensa ion gpov alone o etheigLabor Cod,yolu must foyou nnwithb omply� Applicant understands and will comply with all non point
s with such provisions or this permit shat,be deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information Is correct.I agree
to comply with all city and county ordinances and stale laws relating to building construction,and All roof Cove 'ngs to Class"C" rbetter.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities, to
judgments,caste and expenses which may In any way accrue against said City In consequence• Di
of thegrantjngofthispermit. SIGNATURE OF PPLICANT
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 COPV