R 5922 (2) RMIT .
APPLICATION FOR CITY OF CUPERTINO NUMBER PER_ 5922
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 ArD�DRESS n . ,orf
Q1 "a ( � �`+-��u)q I `o RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
VES e—IuntlersaaClassA
NAME �Do -Cn �� / of"Wer"bly is required.
NO Cl Initial I.C.B.O.#
ADDRESS.
li (.� EXISTING ROOF COVERING
PHONE P C.� r� NUMBER OF EXISTING COVERINGS
S2I
CONTRACTOR'S �^ - TO BE REMOVED k�(#'C TO BE RETAINED
NAME 'S' l�W I� V CI Y1
ADDRESS ���S �.. _, L��e TYPE OF ROOF COVERING
CITY 821P /
EXISTING
PHONE �-3 Zz2-- BUILT-UP ROOFLICENSE ❑ ��
NUMBER 3 Z S__ ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business end Professions Code,and my license le In lull force antl
effect. v WOOD SHINGLES ❑
License Claes C 3 9 Lid.Number O Z� �p
Data �� ' q� Contractor S '7 Y% O TiHEH(SPECIFY) ❑
OWNER-BUILDER DECLARATION S�
1 hereby affirm that I em exempt from the Contractor's License Law for the fol wing reason.
(Sec.7031i5,Business and Professions Coe: Any city or county which requires a ermto J
construct,alter,improve,demolish,or repair any structure,prior to its Issuance,also regporeetithe UILT-UPR( ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provision n)1
of the Contractor's License Law(Chapter B(commencing with Section 7000)of Division 3 of the `: yUr G
' Business and Professions Cotln or that he Is exempt therefrom and the basis for the alleged '11 y q�I+HALT 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).); WOOD SHAKES
❑I,as owner of the property,or my employees with wages as their Bole compensation,will do
the work,and the structure Is not Intended or offered for sale(See.7044,Business and Profes-
sions Code:The Contractors 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 hie 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-Wilder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of eaW).
❑I,as owner of the property,em 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 contractor(s)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
C]I am exempt under Sec. ,B&P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: 00
❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which the
permit Is Issued. ^�Id" (�J )3 �/f $eISR11C _Igo
L
❑ have and will the performance
Workers f the work
for Insurance,as requiredsu Sachin 3700's l(7 --71 I
the Leber Code,for the performance of ins work for which this permit Is Issued.My Worker's Q
Compensation Insurance cer��rler antl Policy number are: Total 1�V�
Cantler n � ;=_ Policy Nc. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION the ON INSURANCE N.C100)o �R A ^ '7
(This section need not be completed If the permit Is for one hundred dollars($100)or lase.) fc 1/rJ- ,Oy
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any person In any manner deo as to become subject to the workers'Compeneatlon Law-of call. All roofs Shall be inspected prior to any roofing m erial being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTCE TO
ealpositilExemption,you
should
subject .tthWorkers'C mpeno provisions ofheLaborr Code, must comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. source regulations.
I certify that I have reed this application and state that the above Information Is correct.I agree
to comply with all city and county ordinances and elate laws relating to building construction,and All roof coverings to be class" "or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for inn
spectlon purposes.
(Wel 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 on consequence
of the 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 -