R-5428 (2) •. APPLICATION FOR CITY OF cuPERTINO PERMIT
U BER R- 5428
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS
/o-777 Z_;X')ry(Gf RESIDENI_COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES [:] If yes–I understand that a Class A
NAME �S e�� KCL. _ cof assembly is required.
95'dr NO Initial I.C.B.O.e
ADDRESS—Z O 7-7/7 Z_ 4-74fa Vi5-6, l7y. (fgg b4l 0 EXISTING ROOF COVERING
PHONE l �8� /30 _ 0.30 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S /+
NAME- Da At n y s TO BE REMOVED _TO BE RETAINED
ADDRESS
TYPE F R20 VE I
CITY S zip 00 7` 5aIC. EXISTING
PHONE op')
BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES. • Q
LICENSED CONTRACTORS DECLARATION <
I hereby affirm that I em Ilcimai d under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Cotle,and my license Is In full force and
effect' WOOD SHINGLES
License Class B Lic.Numberr� 6 6 996
Date //' 3'9-7 Contractor OTHER OTHER(SPECIFY)
OWNER-BUILDER DEC LA ATION PROPOSED
I hereby affirm that I em 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
construct,alter,Improve,demolish,or repair any structure,prior to its Issuance,also requires the BUILT-UP ROOF
applicant for such permit to fila a signed statement that he is licensed pursuant to the provisions y F�Il�ss
of the Contractor's License Law(Chapter 8(commencing with Section 7000)of Division 3 of the P p� A D
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES El
exemption.Any violation of Section 7031.5 by any eppllcont for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).): NOV A[o
01,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES If
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
alpnsCotle:The Contractor's License Law does not apply to an owner of property who builds or WOODSHINGLES CITYUt- I,UCkffIlIVU
Improves thereon,and who does such work himself or through hie own employees,provided that
such Improvements are not Intended or offered for sale.II,however,the building or Improvement
Is said 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,all owner of the property,am exclusively contracting with licensed contractors t0 constructte-
the project(Sec.7044,Business and Professions Code:The Contractor's License Law dose not PROVIDE I.C.B.O.REPORT NO. 3 n 9
apply to an owner of property who builds or Improves thereon,and who contract.for such protects
with a contractor(s)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 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:
have antl will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Buildinges rovIdod for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is Issued. Seismic
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Cade,for the performance of the work for which this permit is issued.My Worker's 0— 3 '97 /j Total
Compensation Insurance carrier and Policy number are ./ 00.
Carrier L(nf[�.n �!g 005_a. Policy No. 7v�C �i-�ASA-00 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE IN
(This section need not be completed It the permit Is for one hundred dollars(4100)or less.)
I certify that in the performance of the work for which this permit a Issued,1 shell not employ
any person In any manner so as to become subject to the workers'Compensation Laws of Cau- All roofs shall be inspected prior to any roofing material being
fornla. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply*with all non
x subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pPpoint
with Such provisions or this permit shall be deemed revoked. source regulations.
I certify that I have read this application and stale that the above Information Is correctt agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
ep en purposes.
(Wagree
(We)agree to cave,Indemnify and keep harmless the City of Cupertino against Ilebllltlee,
judgments,wets and expenses which may In any way accrue against said City in consequence SIGNATURE OFAPPDATE
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