R 5227 (2) PERMIT R_ 5227
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
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS ,_qqq
111377 Zit RESIDENTIAL✓ COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE ARE
A
NAME `V ' ' 1 a.f I� �Oy (71.I YES %yI assembly is arequ red.nd that Class A -
'���� I NO ❑ Initial-,� .O.qI.C.B _f/(�f.y����
x
ADDRESS - KGl .UIStt A- . EXISTING ROOF COVERING
PHONE 9 2t57— 13&. NUMBER OF EXISTING COVERINGS /
CONTRACTO 'S
S /� ko ( ' TO BE REMOVED TO BE RETAINED
NAME I
ADDRESS [-OLp1 r_f L� r�r I l Jc� - S� Is-(Z3 r`
PIE QE ROOF COVERING
CITY 6ZIP J OV 1 1/� I L lGl
EXISTING
PHONE 6� T�COv • BUILT-UP ROOF
LICENSE p
NUMBER l'J673ag• ASPHALTSHINGLES ��/ ❑
LICENSED CONTRACTORS DECLARATION 2
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ;3��
7000)of Division 3 of the Business and Professions Code,and my license is In lull force and
effect. f
&S 73'10! WOOD SHINGLES �C
License Claes 2 Llc.Number
Date�'_ 13 Contractor�"�e.Sl'SfnO% jh�1�C0 OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED A
hereby affirm that I em exempt from the Contractor's 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.to fildemolish,signedtaementthte.prior tolls issuance alsorequlrestne BUILT-UP ROOF ®� .g �wp�
applicant for such permit to lilaaor re alma structure,
that he Is licensed to Its
seance the Provisions
• of the Contrector'6 License Lew(Chapter g(commencing with Section 70001 at Division 3 of 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).): ( �Y Ur CUPEH FIND
❑I,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 Bele(Sec.7044,Business and Profes.
dans Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself ar through his own employees,provided that ❑ _
such Improvements are not does such
or work
for sola.If,however,the buddingemployees,
or improvement
Is sold within one year of completion,the owner-bulider 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,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Lew does not PROVIDE I.C.B.O.REPORT NO. TY f
apply to an owner of properly who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
[II am exempt under Sec. ,B a P.C.for this reason
Owner Date APPLICATION DATE. VALUATION EE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Concent to self-insure for Worker's Compensation, BUIId In ---
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this ^ g
permit Is Issued, SbO Seismic 430
❑I have and will themaintain Workers f the work
for Insurance,as required Is i by Section 370001 /
the Labor Cotle,for the performance of the work for which this permit le Issued.My Workers J _ /
Compens(etlon insurance carrier en Policy number are: Q �s Total
Carrler_S Ahe RAKd Policy Na.133g�3� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.]
(This soctlon need not be completed if the permit is for one hundred dollars fill 0)or less.) �/
I certify that In the performance of the work for which this permit Is Issued.I shall not employ f.
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell- All roofs shall be inspected prior to any roofing material being
fornia. i installed. If a roof is installed without first obtaining an
Date i1 •( J— `^' Applicant �J_(LYh, "� inspection,I agree to remove all new materials for inspection.
NOT become
subject to the a WoTO P ers'Compensetlon provlPLICANT, If,after slone of ththis e lLabor Code,cate of Exemption,
must forthwith 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 I have food 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 class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In. 1 9
apache)purposes.
(We)agree to save,Indemnity which
keep harmless to City a against
Cupertino¢talc!liabilities,
' of the granting of this pecoats and rmit es which may in any way accrue against geld City inconsequence 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY