R 5264 (2) PERMIT R_ 526
4
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
1W DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
U 3 RESIDENTIAL COMMERCIAL OTHER
OWNER'S M�7 HAZARDOUS FIRE AREA
NAME rn� l'IIC� Q ���+ YES ❑ If is requiredtand that. ClessA
`./ roof assembly is required.
NO Initial I.C.B.O.k
ADDRESS— M EXISTING ROOF COVERING
PHONE
I NUMBER OF EXISTING COVERINGS
CONTRACTORS
NAME '�-" MAS JaM S .l \ 1 `gn\I 70 BE REMOVED TO BE RETAINED
ADDRESS (.� 1-7 V\ TYPEIN
CITYanP— EXISTING
PHONE 7 y -ya�� BUILT-UP ROOF ❑
LICENSE ❑ ���
NUMBER Z, ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby affllm that I em licensed under provisions at Chapter s(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,antl my license Is In lull brae and
affect. _ WOOD SHINGLES ❑
License Class �- 3 Lic.NumberZ
OTHER(SPECIFY) ❑
Oete '� � f.��� � Commclor Q ,
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am 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 to
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,el so requires the BUILT-UP ROOF
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 8(commencing with Section 7000)at DlvleIon 3 at 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 of not more than live hundred dollars($500).):
❑l,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profile.
alone Code: The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES �� 0
Improves thereon,and who dose such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.ll,however,the bul lding or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that no did OTHER(SPECIFY)
not build 1,as
Improve for purpose of eec
❑I,ec owner of the property,em exclusivelyProfessions
Code:
T e C licensed contractors to construct
the project(Sec.7044,Business hand Pr or Improv Code:The Contractor's acts for
Law does rojnot PROVIDE LC.B.O.REPPIA�I�p
apply to c contractor(s)
owner )properly who ant t or Ie Contra thereon,and who contracts for ouch projects VF`•r�p�t
wHha am
neer Se pursuant to the Contractors License Low. PROVIDE MFGR.INSTALLATION V$PE�mt�e
❑I em exempt under Sec. ,B 6 P.C.Mr this reason x+y
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, BUlldln
as provided for by Section 3700 of the Labor Code,for the performance of the work for which file g
t, permit Is Issued,
Seismic
]I have end will the pelrf Worker's Compensation the work
for which this as required by Section 3700 or
the Labor Cade,for the performance of the work for which ihle permit Is Issued.My Workers f s
Campanile ion Insurancecarrier ane laypom�er�er�La�y/�J1 s/"�� Total
a Carrier -"^PolicvNo. J .373acZ2 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 Will.) rzTurc
I certify that In the performance of the work for which this permit Is Issued,I shall not emploo
any person In any manner so as to become subject to I or are Compenaetlon Laws of gag- All roofs Shan be inspected prior to any roofing material being
forme. ` installed. If a roof is installed without first obtaining an
/�
Date f/_T AppII inspection,I agree to remove all new materials for inspection.
NOT ICETOAPPrs'Co :.pgeHermaking ovisio C cate Labor Exemption,
mustfothwou lihfecome
comply Applicant unders n d will comply with all non point
subject m ha Workers'Com enaater provision the Leber Coda,
with such provisions or this permit shall be He, ad revoked, source regulatl
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 laws relating tobulltllnpConstruction,and All roof cove ' tob cls s"C°Orb er.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
ep We) purposes.
(We)agree to save,Indemnexpenses
and keep harmless wa the City of Cupertino against liabilities,
ence i
judgments,costs and expenses which may In any way accrue against said City In consequence
of the granting of this permit, SI F I AN 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