R 5845 (2) APPLICATION FOR CITY of cuPERTINo
NUMBER PERMIT
R- 58 4 5
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(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 /,/.,•.// y� J 7
C/S—i/ e'401911 W y RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
��,),x� , VES ❑ If yes—assembly
its req that a Class A
NAME / /G C/C� '` `C 4k.�1 rrwt assembly is required.
- NO ❑ Inthal I.C.B.O.ft
ADDRESS ^J / ��
EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACT`QR'S/J, /
NAME J'� " TO BE REMOVED keS TO BE RETAINED
ADDRESS " ` J EXISTING TYPE OF ROOF COVERING
CITY 8 ZIP Y / C L
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER Z ASPHALT SHI GLES ❑
LICENSd under RACTO provisions of Chapter 9(N
hereby affirm that I em usi n ss under fessionsof e,and B(commencing with Section WOOD SHA
7000)of Division 3 0l Me Business and Professions Code,entl my license Is In lull force and
effect �/� WOOD SHIN L
License Claes 3� Up.Number / /� �'— ❑
p/- / Zc� OTHER(SPECIFY) E]Date 3 Contractor r
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for I following naso .
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,suer,Improve,damollsh,or repair any structure,prior to etc Issuance,also require.the. BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter a(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 ASPHALM SMl N(ILES Elexemption.Any violation of Section 7031.5 by any applicant for a permlt subjects the applicant to
e civil penalty of not more than five hundred dollars($500).), WOOD SH
❑Irks and
er the structure
cture i not I tendedmy employeeswithwages as(Sac.their Bole rgmpesse and
Pr fes.l do g ` ` ANS' ❑
the work,entl Me structure Is not Intended m offered for sale(Sec.owner
of Business entl Promer
Impr Code:The Contractor's Licence Lew does not apply rthrotoenowner of property who idedtar WO INGLES ❑
Ira roves thereon,and who does such workhimselffoci or through his own employees,Improvement
that .(� ( S �1�(
such Improvements are not completion,
leb n,or ownerforleer.ill however,thebuilding or 1g that he did OIAERYJP961 t1YU ,—/ cr0mg
n sold tbuild or
provne e for purpose
sthe owner-builder will have the burden of proving that he did 'tT./. l
not build or Improve for purpose of sale.).
❑I,as owner of the property,em exceusevaly 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 Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
[II em exempt under Sac, ,B 8 R C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: 23 0
❑1 have and Ill maintain a Certificate of Consent to self-Insure for Workers Compensation, Building
as provided for by Section 37M of the Labor Code,for the performance of the work for which this y/I'.�p( f/yT
permit is leeuetl, •�j� ` // D /0 O Seismic
❑ have and will the pert Worker's Compensation the workfor Insurance,as required Is I by Section orb 0l 1 /�
_the Labor Code,for the performance of the work for which this permit le leeuetl.My Workers / r O
Compensaif In u nce c alar and Policy number are: / Total
Carrier � � y7[l Policy No.LY�6 97 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE N.C.D
(This section need not be completed If the permit Is for one hundred dollars($700)or Isis.)
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 call. All roofs shall be inspected prior to any roofing material being
manes' installed. If a roof is installed without first obtaining an
Data 7_ 'ZG 9f Applicant /11" installed.
inspection,I agree to remove all new materials for inspection.
subject t0 the Worrkers'CompeCE TO APPLICANT: f,after nsatlon provisions of tat c borrCode,you mustufothwshould
thbcomplyy Applicant understands and will comply with all non point
with such provisions or this permit shaNbe 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 •overings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
sp e) purposes.
(W
(We)agree to save,Indemnity and keep harmless the Clry of Cupertino epalnel liabilities,
judgments,crate and expenses which may In any way accrue against said City In consequence
of the granting of this permit. UR F 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