R 5567 (2) PERMIT R_
APPLICATION FORITY OF CUPERTINO, NUMBER 556 7
REROOF PERMIT NSPECTION DIVISION ;,' ' PERMIT EXPIRATION
(408)777.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Pi M5180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
Q�{ �1 n(J-
O RESIOENTIAL_/�' COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME 'UL/F�l l= GSSE LS 'tT/ 1 - YES ❑ Ir000ff�undehand fired.hat Claw
NO assembly required.
(nidal I.C.B.O.If
ADDRESS /0 ` 60 MA-dco-* j EXISTING ROOF COVERING -
PHONE 737— ' II yS .. NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S q t � r
NAME W ILL 141 n S 26o4r. TO BE REMOVED TO BE RETAINED
ADDRESS � ITYPE OF ROOF COVERING
CITY&ZIP -/031 y L4-i and A-s I,JA-r Inbprxam.io .
T EXISTING
PHONE �Z'' 512-0 BUILT-UP ROOF ❑
LICENSE ❑
NUMBER L/Iyof? ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter (commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,entl myy license le In lull force entl
sisal. WOOD SHINGLES ❑
License Claes C' 3q Lie,Number k/T/7 T'/c y9
Date 081-7-7 Contractor \V-b OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following reason. PROPOSED
(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 file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter g(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the heels for the alleged SPHALT SHINGLES f{0 yR t1REa lv
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to r
a civil penalty of not more than five hundred dollars($500).):
01,as owner of the property,or my employees with wages as their sole compensation,will do SHAKES ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes.
slons Code:The Contractor's License Law does not apply to an owner of property who builds or S GLE$ ❑
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 building or Improvement /
to sold within one year of completion,the owner-buildor will have the burden at proving that he did R( ECIFY) ❑
not 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 Coda:The Contractor's License Law does not I.C.B.O.REPORT NO.
apply to an owner of property who builds or improves thereon,and who wntracts for such projects
with a wntractor(s)licensed pursuant to the Contractors License Law.
[IPR IDE MFGR.INSTALLATION SPECS.
I am exempt under Sec. - ,B&P,C.for this reason
Owns Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATEI VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the fallowing declaration: A
❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, MI Buildin
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this __
permit Is Issued. nnII1j
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 o1 `.1n(l� 71 p /D 000 . Seismic
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's hu 18
-Compensation Insurance carrier and Policy number are: Total
Carver SllA41e F"Ad Policy No.fy87765y- %7 GilIt49fGI�NA ORIZATIONAT
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(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 employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Call. All roots s al a inspected prior to any r of g m teria eing
hernia' installed. If a roof is installed witho t first obtaining an
Date o �g 9� Applicant �^� inspection,I agree to remove ell new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate 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 shalObe deemed 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 laws relating to building construction,and All roof coverjngs to be classbetter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes. , Q
(We)agree to save,.indemnity and keep harmless the City of Cupertino against Ilabltllles, �_
judgments,costa end expenses which may in any way accrue against said City In consequence
m be granting of mie 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY - )