R 5390 (2) ti • '
PERMIT
APPLICATION.FOR CITY OF CUPERTINO NUMBER R- 5 3 9
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(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
/O to RESIDENTIAL COMMERCIAL OTHER
OWNER'S (� HAZARDOUS FIRE AREA
NAME D+�Yc/s.QX- / / (�-�>�,OL. - YES ❑ If yes undersWrid theta ClassA
roof assembly is required.
NO ❑ Initial I.C.B.O.IS
ADDRESS LL^ EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS /
CONTRAC
TO BE REMOVED / TO BE RETAINED
NAME
ADDRESS `Q �n / -�-/ F ROOF COVE I
'CIN&21P •7 OI .
d• 9 4 3 0 6 EXISTING Six
PHONE 50 44,7 — 37 a BUILT-UP ROOF ❑
LICENSE �$
NUMBER 1 ASPHALT SHINGLES L�
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8(commencing with Sedlon WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
q WOOD SHINGLES
License Clesa �� Lic.Number 2 �v ❑
Date r71 �S Contra _ OTHER(SPECIFY) P Pli g
OWNER-BUILDER DECLARATION4PROPOSED
I hereby e8irm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031,5,Business and Professions Code: Any city or county which requires a permit to 7dL-sJri+'
construct,alter,Improve,demolish.orreNAY
any structure,prior to its Issuance,also requires the BUILT-UP ROOF t�
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
oI the Contractor's License Law(Chapter 8(commencing with Section 7000)of Division 3 of the C,
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES CITY UP
exemption.Anyviolation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty al not more than five hundred dollars($500f): L
❑I,as owner of the property,or my employees with wage:as their sole compensation,will do WOOD SHAKES El Ll
the work,and the structure is not Intended or offered for Sala(Sec.7044,Business and Protan- h 3 5
alone Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through h1:own employees,provided that ❑
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with Ilcen:ad contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Lawdoe:not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(:)licensed pursuant to the Contractor's License Law, PROVIDE MFGR. INSTALLATION SPECS.
❑1 am exempt under Sec. ,S$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:
❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, 97-421115
as provided for by Section 3700 o1 the Labor Coda,for the performance of the work for which this /� /� ••f i Building
p r tlassued. �l 156/ !y]' j/'� Seismic '�
r I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of p
t Labor Code,for the performance of the work for which this permit Is Issued.My Workers / ] 5..�
Compensation 1 urn ce carrier end Policy number are: �`�1 Total
Carrier FLt�HOCr Policy N4J 1 L`g]-LI Zs PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' /T
COMPENSATION INSURANCE N.C.❑ V
(This section need not be completed 11 the permit Is for one hundred dollars($700)or leas.) a �yV7J V GGr J ��4a
1 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 sublecI t the Worker:'Compa aeon Law:of Cali- All roots Shall be inspected prior to any rooting material being
fornia, installed. If a roof is installed without first obtaining an
Date ---S—/ S Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Cartificalle,of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shall be domed 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 law:relating to building construction,and All roof cov Ings to be class"C"or befter,
hereby authorize representatives of this city to enter upon the above-mentioned property for In- /
epapurposes.
(We)
agree IS save,Indemnity and keep harmless the City ai Cupertino against liabilities,
ence T
.1 the gnte,coats end expenses which may in any way accrue against geld City In wnaequence
of ino grendng of min permit. SIGNATURE O 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 `