R 5987 (2) ''�_
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R" 5 9 8 7
INSPECTION DIVISION ' PERMIT EXPIRATION
REROOF PERMIT _ (408)777-.3228. PERMIT EXPIRES IFWORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS p�x I
STeor RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME a�S _i^ VES ❑ Ifyms-lun�srequiretd, ClassA
roof assemb eq
NO ❑ Initial LC.B.O.A '
ADORES h'' [!-
EXISTING F VE I G
PHONE — Q O NUMBER OF EXISTING COVERINGS
CONTRACT R'S //.,,•.,, -•�/4
NAME OS "��OS �0 is r 'h TO BE REMOVED TO BE RETAINED
ADDRESS / (� //�7 / LOS S' TYPE OF ROOF COVERING
CITV&ZIP EXISTING
PHONE S 2,33 BUILT-UP ROOF ❑
CENSE
NUMBER 1 W ASPHALTSHINGLES ❑
LICENSEDdunderCONTRACTORSsof Chapter 9(Nkr
hereby viaffirmsion that I em licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
]000)of Division 3 of the Business and Professions Code, tl my license I I lull force and
effect.
WOOD SHINGLES ❑
License Cies.��-.39 Llc.Number .
Data Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors 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 B(commencing with Section]000)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 for a permit subjects the applicant to
a civil penalty at not more than live hundred causes($500).): WOOD SHAKES I,as owner of the property,or my employees with wages as their 8019 comp9nsalion,win do ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes-
sions 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 or through his own employees,provided that l
such improvements are not intended or offered for sale.It,however,the building or Improvement
is sold within one year of completion,the owner-bullder will have the burden of proving that he ditlOTHER(SPECIFY) Elnot 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.
apply to an owner of property who builds or improves thereon,and who contracts for such projects {�•J��
with acontlicensed pursuant to ma Contractors License Lew. PROVIDE MFGR. INSTALLATION SPECSr.�_
C] exempt I em exempt under Sec. ,B 8 P.G for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
1 hereby affirm under penalty of perjury one of the following declaration: I O
^ r d
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, BUIldlnd L
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this D
permit is Issued. I
l
❑1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of Seismic�'�'J - 8
,the Labor Cotle,for the performance of the work for which this permit Is Issued.My Worker's A , /n
Compene n lnsurancg carrier an icy umber er : OP ISL I 12
flI _ Q
Carrier, olicyNe.�YJ6llG�{�7 � PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 11UJV 40r _ Q
(This section need not be completed if the permit Is for one hundred dollars($100)or leas.) V O li A 0 2 -9 8
1 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 Cali. All roofs shall be inspects o anyTngfiriN rvlaterial being
forma. installed. If 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 Applicant understands and will comply
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP ply with all non point
with such provisions or this permit shalCbe deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information Is correct.)agree
to comply with all city and county ordinances and state laws totaling to building construction.and All roof coverings to be class"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes.
(W /�/ �'
(Wel agree to save,indemnliy entl keep harmless the Clty of Cupartlno aBelnel Ileblllties, ?-S— 8.
judgments,costs and expenses which may In any way accrue against said City In consequence SIGNATURE OF APPLICANT 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