R 5238 (2) PERMIT R_ 5 2 3 8
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
RESID
ESS LA-6'20100 � 000Ag W ENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
d A YES C] , If yes—I understand that a Class A
NAME /1/11k.� !'(.C✓LI1$ roof assembly is required.
^
1,10i Initial I.C.B.O.N
ADDRESS— ZO I o o L� VVll Lel' EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS /
CONTRACTORS
R'`
NAME—W ,uII 2004�i_1 TO BE REMOVED / TO BE RETAINED
r ADDRESS TYPE OF ROOF COVERING
CITY&ZIP 10314 L45 00D43 wLAI
EXISTING Pill
O�
PHONE—
LICENSE
ZS2- SIZO �i4 C�,tIyO FQ
BUILT-UP ROOF j' Ur F
p[�yy
NUMBER 41 L40 9,1 ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION �p �i888
I hereby affirm that I em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES � 1
7000)of Division 3 of the Business and Professions Code,and my license le In full force and
enact. WOOD SHINGLES ❑
License Claes C_ 31 Llc.Number � o
Date (( ' elk contractor—I, ' OTHER(SPECIFY) PAID E]
OWNER-theoERDECLARATION
rsLicese PROPOSED 05q�gryl�
I hereby affirm Bu that am exempt from the e: Any
License Lew icr the following reason, l�®\p 1�.T01
(Sec.7031.5,Business and demolish,
or rep Code: Any dry or county whish requires a permit to IN V
construct,alter,such
Improve to file signed statair eny ment that
prior tope Issuance,pursuant to the qulres the BUILT-UP ROOF
applicant the lit for etch permit a 81e a signed statement that he Is licensed pursuant to the provisionsof thry
I the ss and
License Lew(Chapter h(commenting with Section 7000)of (or the 3 of the G11-Y i OF uUr Eh
Business entl violation of
or met he to exempt therefrom and the Dale for the oantto ASPHALT SHINGLES
exemption.Anyyf of onof Sect ion hundred
byany applicant for apermit sucjects the applicant to
e dull penalty of not more than five hundred dollars($500).):
E]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-
sions Coe:The Contractors License Law does not apply to an owner of property who builds or WOODSHINGLES
Improves thereon,and who does such work himself Or through his own employees,provided that ❑
Such Improvements are not Intended or offered for sale.If.however,the bulltling or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he didOTHER(SPECIFY) Elnot build or Improve for purpose of sale.).
❑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.S.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.
❑1 em exempt under Sec. ,B 5 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION F APPLICATION DATE VALUATION PERMIT E
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to sall-insure for Worker's Compensation, BUII n
as provided for by Section 3700 of the Labor Coo,for the performance of the work for which this
permit is Issued,
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of /I/7 _`v Seismic
the Labor Code,for the performance of the work for which this permit Is Issued,My Worker's Total
Compensation Insurance carrier and Policy number are:
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.[]
(This section need not be completed If the permit Is for one hundred dollars($100)or lees.)
I certify that In the performance of the work for which this permit Is Issued,I shall not emtoy
any person In any manner so as to become subject to the Workers'Compenastion Laws of all. All roofs shall be inspected prior to any roofing material being .
fornix' / installed. If a roof is installed without first obtaining an
Date I I S Q Applicant V-%J4JL inspection,I agree to remove all new materials for inspection.
ecome
subject too the Workers'Compensation provisions O APPLICANT: It,after ofthis sthe flLabor Code,cate of Exemption,
mustforthwith lbcomply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. source regulations. -
I certify that I have reed this application and state that the above Information Is correct.)agree
to comply with all city and county ordinances and state laws relating to bulltling construction,end All roof coverings to be class"C"or better.
hereby authorize representatives of this city to Doter upon the above-mentioned property for In. ,x _� vt
ep(We) purposes. .•/C/I JI/`/I (,}/(/�_
(We)agree to save,expenses
and keep hay way the Clry ai Cupertino ygelno liabilities, !f J
jutlgmente,coats and expenses which may In any way accrue against said Clry Inconsequence
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY