R-5381 (2) �iNUMB PERMIT 5381
APPLICATION FOR CITY OF CUPERTINO
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (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
( 0(p8Z /10 to �-4 -pN,.q_ C,� RESIDENTIAL COMMERCIAL OTHER
OWNER'S (� IHAZARDOUS FIRE AREA
lr
NAME J6vvyll TIN' C�tWwck YES ❑ roof assembly srequirled. Dla55A
NO ❑ Initial LC.B.O.N
ADDRESS EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
NAME A It 3e_",BvL S ,q [yLc- TO BE REMOVED TO BE RETAINED
ADDRESS 5 94 . 0 lik" S� J3� q5-111 TYPE OF ROOF COVERING
CITY&ZIP 'C U, t _
EXISTING
PHONE 1�!J -7 2"��[-4 S's BUILT-UP ROOF ❑
NIUMBER J8D I ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm 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
ar'r'est' (� L WOOD SHINGLES �J�
License Class I Lis.Number `� 13Q0
OTHER(SPECIFY) /�❑
Date��Contractor y
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Lew for the following reason.
(Seo 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 ❑
applicant for such permit to fife a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the r
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHIN
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to DT l/}. T�
e dull penalty o not more than five hundred dollars with
wag.): WOOD SHAKE 1� ��L
❑I,as owner of to property,or to employees with wages as c.7 sola compensation,will s.
the work,and se structure Is not intended or offeredtfor said(Sec owner
of Business and mods a r�-�
Bions Code:The,an who
License Lewdoes elf or
through
own employers,whobuildsor WOOD SHINGL S OCT 1 lygg7
improves tenon,end who tloen such work himself of oIf,ho his own employees,provided teat
such improvements are not Intended the
offered for sale. ill however,the en of pr or Improvement
istbuild or
year of forpurposetofSaI .owner-bulltlerwillhave the burdenofprovingthat hedid OTHER(SPECT ❑
not build or improve for purpose of sola.).
❑I,as owner of the property,am exclusively 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.REP
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
[:]I am exempt under Sec. ,B 8 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: q
E]I have and will maintain a Certificate of Consent to sell-insure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
p rmil s leauetl. Seismic
have and will maintain Workers Compensation Insurance,as required by Section 3700 of - _
L r Cotle,for the performance of the work for which this permit is issued.My Worker's Total I—////—Jl�f'—`.J�—
Compensation Insurance carrier and Pol+1cy number are G
Carrier LL�a�Z 1 ['�.�rMhIM Policy No. IZ'O ��Cl'4o PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTIO FROM WORKERS'
COMPENSATION INSURANCE N.C.[]
(This section need not be completed it the permit Is for one hundred dollars($100)00)or less.)
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 Ceti- Alifil5ofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOT shoulbecome
subject lo the a Worrkeras'Compens tl n prrovisionis of thelLaborr Code,cate you mustof Exemtion, ufo thwiith comply Applicant understands and will comply with all non point
with such provisions or this permit shalC 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 state laws relating to building construction,and All roof coverings to be lass"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property or In-
spection purposes. Z
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities, Qs_��� 17 ar a:F1 7
judgments,costs and expenses which may In any way accrue against said City In consequence -T—
ot the granting of this permit. SIGNATURE OFAPPLICANT 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