R-5692 (2) PERMIT R_ 5692
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
R ' RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ H yes—I understand that a Class A
NAME Lk_kE_v,, Z roof assembly is required.
N - Initial LC.B.O.e
ADDRESS— 's Q VV�`e EXISTING ROOF COVERING
PHONE — NUMBER OF EXISTING COVERINGS
CONTRACTOR'S /1 ,., f ,,., n
NAME �._C9 S I Z S.tiY-iJ S 12Aa-n-&I L. Q TO BE REMOVED X TO BE RETAINED
ADDRESS (� � ^^ / ^—UJ TYPE OF ROOF COVERING
CITY d ZIP �- 'b1–Y D—� l O� l C-0. 4d, Ill
D 31 "EXISTING
PHONE3 3 q!rBUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ElLICENS D CONTRACTORS DECLARATI N /
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full farce and 2
effect
C 39 04q,A- 3C� (Q WOOD SHINGLES ❑
License Class Dc.Number
Date Contractor OTHER(SPECIFY) ❑ DZ
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 Professions Code: Any City or county which requires a permit to
Construct,after,Improve,demolish.orrepair any structure,prior to its Issuance,alsorequiresthe BUILT-UP ROOF Elapplicant for such permit to file a signed statement that he Is licensed pursuer;to the provisions
• of the Contractor's License Law(Chapter g(commencing with Section]000)of Division 3 of the E]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 no;more than five hundred dollars($500).): WOOD SHAKES
01,as owner of the property,or my employees with wages as their sole compensation,will do
;he work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profiler
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder.111 have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractil licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS,
0 I em exempt under Sac. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby and under penalty of perjury one of the Ito caprin declaration: "$
❑ have end will maintain a of thei Lab of Consent to self-forma for Worker's Compensation, ��� BUI dlf
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this ff�.
permit Is Issued. 1 •Ei` 1
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of O Seismic
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's f
Compensation�Insurance
�carrier and Policy number are: 1 I y� —f ` sl� �Jf LVA„- , 1 � Total
Cerrler0 0--JQVx^ P Policy NibLIA7((I 3 1.5 J PERMIT"AUTHORIZATION DATE
CERTIFICATE EN EXEMPTION FROM WORKERS' ���
COTE OF EXEMPTION
ION NRANGE N.CQ
(This section need not be completed II 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,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 roofing material being
fornia, installed. If a roof is installed without first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If.after making this Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shell be deemed revoked, source regulations. -
I certify that I have read this application and state that the above Information Is correct.I agreeto /�//y/g(�/y_��'_
hereby author all rep and se tabes ordinances to ental upon thelaan to ve-me tined property f and All roof C/ "O be class"�•,,or better.
hereby authorize representatives of this city 10 enter upon the above-mendonetl property for In-
spection agree toe. Lily /
(We)agree to rave,indemnity and keep hay way the Clry ai Cupertino against liabilities, b — G
of t marts,vete and expenses which may In any way accrue against said City In consequence �;
• of lie granting of this permit. SIG URIt1fK E ANT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY _ _ _