R-5610 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5 61
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
Q ` 1� 1 !' kJ� RESIDENTIAL_z COMMERCIAL OTHER
OWNER'S-- HAZARDOUS FIRE AREA
YES ❑ If yes–I understand that a Class A
/
NAME— l(LtA-) Gk A D roof assembly is required.
NO ElInitial . I.C.B.O.11
ADDRESS !D 72)L A I eA-oi \0!1.. EXISTING ROOF COVERING
PHONE -7 NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S J0aT s//L���
NAME 171 G7f'i �.S� '47 ! TO BE REMOVED TO BE RETAINED
ADDRESS ' I / TYPE OF ROOF COVERING
CITY&ZIP -�f L! u✓KIR P Pe-1
r EXISTING
PHONE q'22 q15-5 BUILT-UP ROOF ❑
CENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em Ilcansetl under provisions of Chapter a(commencing with Section WOOD SHAKES [!�
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect' '° WOOD SHINGLES ❑
License Class ` �3 / Lic.Number I'S 3�d � p
Date
(9 --S' 'j•� Contractor /!/ tsFY .r,�r'}F,1-[A. OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to x�
construct,alter,improve,demolish,or repair any Structure,prior to Its issuance,also requires the BUILT-UP ROOF
applicant for such permit to Isle a signed statement that he Is licensed pursuant to the provisions
o1 the Contractor's License Lew(Chapter 9(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
e civil penalty of not more than five hundred dollars SSW).):
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 Profits.
alone Code:Th.Contractor's License Lew 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 ere not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) Elnot build or improve for purpose of sale.).
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bullds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFG,R.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.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: (h
I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, •_�j A /D l `-'� ' BUlldl g
(07
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit''i,s��Issued.
&M( antl will maintain Worker's Compensation Insurance,as required by Section 3700 of UM, Seismic)
the Labor Code,for the performance of the work for which this permit is Issued.My Worker's �•VV �j
Campers bon Insurance carrier and Policy number are: gC Total
carrlerJC_GSA✓�I'tz�IPn;w�/ PollcvNo. laSSYi7/ �: UTHORIZATION DATE
CERTIFICATE OF EXEMPXAON FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed if the permit Is for one hundred dollars($100)or lase.)
I certify that In the performance of the work for which this permit Is Issued,I shell not employ
any person In any manner so as to become subject to the Workers'Compensatmn Lawa of Celb All roofs Sha be inspected prior to any roofing material being
forms. installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,after making this Certificate of Exemption,you should became Applicant understands and WIII
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pp comply p y with all non point
with such provisions or this permit shall 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 state laws relating to building construction,and All roof cc rin aclass"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes. ` Q�
We)agree tos save,indemnity and keep harmless the City ai Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City In consequence SIGNAII IRE O APPLICANT DATE
of the granting of this permit.
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