R 5465 (2) PERMIT -
APPLICATION FOR CITY OF CUPERTINO
NUMBERR 5465
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS /� p
1015O l-'QpID IQC Il, RESIDENTIAL - COMMERCIAL OTHER-
OWNERS
THER
OWNER'S` Le��f��n�t�� HAZARDOUS FIRE AREA
NAME�/L�K-1 1 IW I YES ❑ If yes-I understand trial a Class A
__-per q ��,,L, roof assembly is required.
ADDgESS IOIii/ 11 K�IIVT It„�yC,t ( ,(] ni NO ❑ Iniaal I.C.B.O.#
7 EXISTING R
rOOF COVERING
PHONE / — �/Q/I NUMBER OF EXISTING COVERINGS
CONTR/A�CTOR�'Sq� '�,.,�/�
NAMEAIICn.'l_-C//.(4\Z'}J�L7��TQJQDCI n`a 1 JQCtl TO BE REMOVED I TO BE RETAINED
CITY&ADDREZ P y`��95�)I TYPE OF ROOF COVERING
EXISTING ❑ / e
PHONE BUILT-UP ROOF
NUMBERASPHALT HIN LE
I I LA S G S ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that am licensee under Professions
of Chapter 9(commencing with Section WOAD SHAKES LLI�
7000)of Division 3 of the Business and Proleeslona Cotle,and my license is In lull force and
effect. 5112/ WOOD SHINGLES ❑
License Class G Lic.Number��11
Data 2 Contractor al fla Jn OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am 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 file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter fl(commencing with Section 7000)of Division 3 of the L�
• Business and Professions Code)or that he is eexxoommpp}}�therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by,1rjNappliceh 1yreyefrap subjects the applicant to
a civil penalty of not more then five hundred chats($500),):
❑I,as owner of the property,or myempl Be§with wdge�ag eiraolcmpan to tilde
WOOD SHAKES ❑
the work,end the structure Is not Intentlatl rldfkred for eels(9 .7044�uaines a Pole.-
.lone Code:The Contractar'e License Lew Ree not�apply to an owner of property ullds or WOOD SHINGLES
Improves thereon,and who does such work himself drlt ATh a9v nemployees r dad that ❑
such Improvements are not Intended or offer etl Ipr sSIAMM hh__0 gq9����tthJe i ovemenl
Is sold within one year of completion,the oaprbulltler will neve th9bu7rgro n at he did OTHER(SPECIFY) ❑
net build or Improve for purpose of sale.). /�
❑I,as owner of the property,am exclu Ivppl o t ting with licensed contrac r construct
the project(Sec.7044,Business end Pro Code:The Contractor'.Licene does not PROVIDE LC.B.O.REPORT NO.
apply to an owner of property who builds who contracts for a It projects
with econtrector(.)licensed pursuant tothe Contreco - PROVIDEMFGR.INSTALLATIONSPECS.
❑1 am exempt untler Sec, ,B this reeaon
OwnerDate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to self-Insure for
eprovitle or by Section 3700 of the Labor CotleWorks
permit seuetl. , un
have entl will maintain Workers Compensation Insurance,as required by Section 3700 of ) ' )339 Sells m is / a
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's 8 Y Q
Camps ion Insu nce cards and Policy numb gr re: Total/ r
Carrier I L n Policy NO) PERMIT AUTHO DATE
CERTIFICATE OF EXEMPTI FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) 6
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 roofs shall be inspected prior to any roofing material being
fornia. installed. It 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
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 sha@b deemed revoked. source regulations.
I certify that l 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 coverings to be class yr better.
hereby authorize representatives of this city to enter upon they of Cupertino
netl property for in.
spection purposes.
(We)agree s save,indemnify and keep harmless the City ai Cupertino egainel liabilities,
ofjudgments,the gran coats and expenses which may In any way accrue against said City In consequence ) NATURE OF APPLI T DATE
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