R-5452 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5452
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 c-y
1 s — RESIDENTIALX_COMMERCIAL OTHER
OWNER'S . HAZARDOUS FIRE AREA
/
NAME � `V YES ❑ Ifyes-lunders
assembly starequihat
roa Class A
NO Initial I.C.B.O.tt
ADDRESS O-115e�$ ��-S1��iPE c�r EXISTING ROOF COVERING
PHONE O V — [7. $O NUMBER OF EXISTING COVERINGS
CONTRACTOOR'SG / n
NAME I—G LL— � /C GirUEN TO BE REMOVED TO BE RETAINED
ADDRESSTYPE OF ROOF COVERING
CITY&ZIP 400 �fENDERSoN Aute 'f/
p EXISTING
PHONE�[4�� ! 9� �� $l� BUILT-UP ROOF ❑
LICENSE
NUMBER , ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby adlrm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect +� p J p r/ WOOD SHINGLES El
License Class `—� • Lid.Number D 7/
d
Dale
Contractor ex OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractors License Lew for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit t0
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF V
applicant for such permit to file a signed statement that he Is Ilcensetl pursuant to the provisions
of the Contractor's License Law(Chapter 9(commencing with Section]000)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 o1 not more than five hundred dollars($500).):
[J 1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES El
the work,and the structure is not Intended or offered for sale(Sec.]044,Business and Profits.
sons Code:The 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 are not intended or offered for sale.IL 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) El
build or Improve for purpose 01 sale.).
❑1,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Coda: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.
D 1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
hereby storm ill under penally of perjury one of the following sure for
Worker's
o P A I D
❑i have and will maintain a Certificate of Consent to self-insure for of the oCompensation, BW ldm� 000
as provided for by Section 3700 of the Labor Cotla,for the performance of the work for which this l
pe��rmsJJ is a'""a. Seismic
`Grl have and will themaintain Workers Compensation Insurance,as required by Section 3700's T O o �•rypa11
Ihe�xLLttbor Code,for the performance of the work for which this permit is d by S.My Worker's Fr ItG!W
Compensation Insur�zn�ce carr�lojr'ens PJol�icy numer ere: Total
Carrier S���G ' u�✓ Policy Na.l3g�s�a—9��( t,tpEAMITIAUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed if the permit Is for one hundred dollars(5100)or less.) O
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'Compensation Laws 01 Cell- All roots shall-be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subject
NOTICE
to theOWorrk Workers'Compei,after nsation provisionis ofthecate of Labor Code,Exemption,
must forthwithcecome
omplyApplicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. Source regulations.
I certify that 1 have read this application and state that the above information Is correct.I agree
to Comply with all city and County ordinances and slate laws relating to building construction,and Allseahcoverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
apache)agree toe. A
(We)agree to gave,expenses
w and keep harmless the City ai Cupertino said Ci against Ileblllllee, / _J 7
judgments,the gran coats and expenses which may In any way accrue against Geld City In consequence j
. of the granting of this permit. SIGNATURE OF APPLIC T7 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