R 5798 (2) PERMIT R_ 5798
.
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
70 . ES /�1•r /'}
G' RESIDENTIAL COMMERCIAL OTHER
OWNER'S c� HAZARDOUS FIRE AREA
NAME Al142-' G rJ '!F-7'Ell" YES ❑ If yes i understandthat. Cl, -
of assembly is required.
NOImtlal' LC.B.O.#
ADDRESS
J OZ E5 r2�=S EXISTING ROOF COVERING .
PHONE. p — ® NUMBER OF EXISTING COVERINGS 2,
CONTRACTOR'S
—(� �' V /` �� /— T✓r/" TO BE REMOVEDy TO BE RETAINED
NAME
ADDRESS /y Q TYPE OF ROOF COVERING
CITY&ZIP-TS `, �� Z �• S/ • / �/�Tr��l"(/s G 7 5 r EXISTING
PHONE '— ` d BUILT-UP ROOF ❑
LICENSE 7 CJGJZ 3 L ASPHALTS LES
NUMBER t !! //
LICENSED CONTRACTORS DECLARATION
I hereby affirm Itiat I am licensed under provisions of Chapter 8(commencing with Section WOOD SH ES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect. - WOOD SHINGLES -
License Claes 3 9 Llc.Number
l�9� G IFG RGb�to OTHER(SPECIFY)
Data- Contractor
OWNER-BUILDER DECLARATION PROPOSED
1 hereby affirm that I am exempt from the Contractor's LicenseLaw for the following reason. - '
(Sec.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 El
for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter g(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($500).):
❑1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
alone Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees, mvided that
such Improvements are not Intended or offered for sale.If,however,the building or Pmpmvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) E]not build or Improve for purpose of sale.).
❑I,as owner of the property,em exclusively contracting with licensed contractors to Construct
the project(Seo.7044,Business and Professions Coda;The Contractor's License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with acontlicensed pursuant to the Contractor's License Lew.
[-] exem
PROVIDE MFGR. INSTALLATION SPECS.
I em exemptt under Sec. ,B&P.C.for title reason
Owner Data ATION ATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECUBATION
I hereby affirm under penalty of perjury one of the following declaration: �-y�
I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, C/ NN/P� - �IUsVe Building /�
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this •'H! i
permit Is issued. I F(,(f
❑I have and will maintain Workor's Compensation Insurance,as required by Section 3700 o1 hCfly7 SBI$mID
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's yl1J
Compensation Insure- terrier�s 4Policy number are: ,O Total
Carrier S /C !-r D Policy No 74 97y/V 17a0 PERMIT AUTHORIZAT DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N,O.p
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) (•If. Y C(IJ�
I certify that In the performance of the work for which this permit Is Issued,I ahall not employ
any person In any manner so as to became 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
Date_[_LLJJL_ Applicantp C'it:tee-,-c-. inspection,1 agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,after making this Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor coda,you mast forthwith 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 l have read this application and state that the above Information Is correct.i agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to be class°C"Or better.
hereby authorize representatives of this city to enter uPon the above-mentioned property for In. ,I/��y/�j�
sp ction(We) purposes. G'c a'✓�'Gs�� ( ��h'� 7 ter/
(We)agree to aave.Indemnity and keep harmless wa the City ai Cupertino y Inagainst liabilities, ��
judgments,vete and expenses which may In any way accrue against said City In 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 t .