R 5879 (2) APPLICATION FOR CITY of cuPERTINo
NUMBER R— 5879
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT - (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS
180 DAYS FROM LAST CALLED INSPECTION.
�Iy� '
0 I C A� A I L RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME C /TIL-L.+z��5 {-��c.� YES ❑ If yes
assemnblly s required.derstand that Chase A
NO ❑ Initial I.C.B.O.#
ADDRESS— '� EXISTING ROOF CQYERING
PHONE — (� l I l NUMBER OF EXISTING COVERINGS
CONTRACTO/5'S
NAME
f U 1 �MLOQ 5�2V I G� TO BE REMOVED TO BE RETAINED
ADDRESS �/ [[/_/ (y/ TYPE OF ROOF COV ERING
CITY&ZIP—
EXISTING /
PHONE `/��S// (� BUILT-UP ROOFLICENSE ❑ '
l
NUMBER / t0 ❑ !!! `
LICENSED CONTRACTORS DECLARATION /
ASPHALT SHINGLES
hereby iaffirmnion that I em licensed under provisions of Chapter y(commencing with Section WOOD SHAKES
]000)of Division 3 0l the Business and Professions Code,and my license Is In full torte entl
effect G WOOD SHINGLES
LlceneaFlase�-- Lic.Number �� - ❑
Daley �S' Carl.. �C i OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
1 hereby affirm that I am exempt from the Contractor's License Lew for the following reason. I]
(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 1°VL~JW
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractors License LawSChapter 9(commencing with Section 7000)of 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 fore permit subjects the applicant to
e civil penalty of not more than five hundred dollars($500).):
C]I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES tslBvJ
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Coda:The Contractor's License Lew does not apply to an owner of property who builds or WOOD SHINGLES
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
Is sold 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,as owner of the property,am exclusively contracting with licensed Contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO. UL
apply to an owner of property who builds or Improves thereon,and who contracts Mr such projects GLS
with a contractor(s)licensed pursuant to the Contractor's License Law.
❑ PROVIDE MFGR.INSTALLATION SPECS.
I am exempt under See. ,B&P,C.for this reason
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 sell-Insure for Worker's Compensation, Building //2'00
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is Issued.
��(II 1 have and will maintain Worker's Compensation Insurance,as require by Section 3700 of t(J /V� Seismic 7L�
tb43pbor Code,for the performance of the work for which this permit Is Issued,My Workers //7. 70
/7 '1.J
Compensation'5T4 t6
carrier end Polluumber are: Total
Carrier '5Tmtc �� I✓ Policy No. "'� AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O L;0
(This section need not be completed If the permit le for one huntlred dollars($100)or less.) Gv �/j
I certify that In the performance of the work far which this permit Is Issued,I shall not employ
any person In any manner so as to become subject to the Workers'COmpensatlon Laws of Cell. All roofs Shall be inspected Prior to any rooting material being
fornia. installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
ecome
subject t.the Workers'CompeT CE TO APPLICANT. nsation,after making
roiv sionie f the flLabor Code,cate of Exemption,
must forthwou ithcomplyApplicant understands and will comply with all non point
with such provisions or this permit chalP,be deemed revoked. source regulations.
I certify that I have reed this application and state that the above Information Is correct,I agree
to hereby authorize
all city and county ordinances and tern on the
above-mentioned
conatruelion,end All f00f VBfings to °C or better.
hereby authorize repreeentetives of this city to enter upon the above-mentions property for In. /x' /111 t
speedo'purposes. ` l
(We)agree to save,Indemnity entl keep harmless the City of Cupertino against Ilebllillee, i �/ dl
.f, mens,costs and expenses which may in any way accrue against said City In consequence
of t�e 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
__ OFFICE COPY