R 5896 (2) APPLICATION FOR CITY of CUPERTINO - NUMB R R- 5896
INSPECTION DIVISION PERM IT 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 -
2f342 MIL- r-OPD �� � 9Sa!�
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
/My 5 /'�'�.. YES ❑ If myea-(understand that. Class
NAME ro
/ of assembly is required.
NO X Initial I.C.B.O.M
ADDRESS /� EXISTING ROOF COVERING
.PHONE / NUMBER OF EXISTING COVERINGS -4—
CONTRACTOR'S _
NAMES 1 CNA'/SSA-.UL' P IRCRC9/VG CO �NC, TO BE REMOVED TO BE RETAINED
ADDRESS ^^�� A �3 LS TYPE OF ROOF COVERING
CITY azIP_.2""9 2- L 1NcnLti r4✓e `SE7 /S/
EXISTING
PHONE �{� — 9:K60/' —Ob-'O 9�' BUILT-UP ROOFLICENSE
❑
NUMBER SS 43 6 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full tome and
effect. 5-s
EXP WOOD SHINGLES ElLicense Clens Lic.Number /p
Data Contractor
T OTHER(SPECIFY) ❑
OWNER-BUILDER DEC o PROPOSED
I hereby affirm that l em exempt from the ConlrectoY Cense Law for the tollowinp reason.
(See.7031.5,Business and Professions Code: Any 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 previsions
' of she ssContractorsanPProfessions
Law)or that
8(commencing with therefrom
and 7000)of Division e ale the
exemption,
entl violation of Code)or that he is exempt antforam entl the heels for the alleged ASPHALT SHINGLES
exemption.Any violation of than
fin hundred
by any applicant for a permit subjects the applicant to
e civil penalty of not more then flue hundred dollars($500).):
❑l,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 sale(Sec.7044,Business and Profes.
slons 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 ❑
such Improvements are not Intended or offered for sale,ll,however,the building or improvement
Is sold within one year of completion,the ownerbuilder.111 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(See.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
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&S9 r)11hlwason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATIQ Cx ,r O
I hereby emrm under penalty of perjury one of the following tled u[� pp pp p�6 O
❑Ihave edfor b Section m
aintain 3700 of Cert
ificate bor Consent to the self-insure
for Worker's Com diM, ^��^ V Building d0
as provided for by Section 3700 of the Labor Code,for the pedoLmrrrfe of the work for which this �„ ,..,,cL Q
p
ml Issued. U, x,x,r. /NT�I(1.VXJ
I have and will maintain Workers Compensation Insurance,as required by Seclfobia%bbf q rJ81SfT11C
th r Code,for the performance of the work for which this permit is Issued.My Workers G
Compensation insurance carrier and Policy number are: Total L113.71 ?0
-
Carrier S7247e FLA" PoflcyNo. �r�D�/Sasj PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need not be completed If the permit Is for one hundred doll re flit 00)or lesst O
I Certify that In the performance of the work for which this permit is Issued,I shall not employ �O
any person In any manner so as to become subject to the Workers'Compenemlan Laws of Call. All roofs shall be inspected prior to any roofing material being
fornia. 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 APP comply Applicant understands and will I with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply p y p
with such provisions or this permit shall be doomed revoked. source regulations.
I certify that I have read this application and state that the above Information is correct,I agree
to complywIth all city and county ordinances and state laws relating to building construction end
roof ;overingst b CI r er.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
epe<tlon purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, ,
• judgments,costa and expenses which may In any way accrue against said City In consequence GNATURE OF APPLICANT D E
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