R-5810 (2) l PERMIT R_ 5 810
APPLICATION FOR CITY OF CUPERTINO NUMBER
:]
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS /v',f ,
mfiiii LJL vaf Lvmn/Q RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE ARE
/eA
NAME Pg - L(AN/ L1111271/I YES ❑ If yes-I understand that a Class A
roof assembly is required.
NO Initial I.C.B.O.k
ADDRESS /67 15 L�. SS P�cil e% EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS /
CONTRACC/T''O'RS '
NAMEyV 6/1�^ClZ- �`-OOr�/✓�"+ 'T/N- TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF C VE ING
CITY&ZIP 22 7— TYPE
�t
,qyq Twp p�-v EXISTING
PHONE 3 3 BUILT-UP ROOF
LICENSE
NUMBER 2(1r !i� ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION /�
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and �•
effect.
Z� WOOD SHINGLES ❑ rte
License Class 3 Lic.Number
+L �j Contractor OTHER(SPECIFY) ❑
Date Z
OWNER-BUILDER DECLARATIO PROPOSED
I hereby affirm that 1 am exempt from the Contractor's License Lew lot a follo Ing to
n. r
(Sec.7031.5,Business and Professions Code: Any city or county which requires a per it to 0
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 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 for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($501 WOOD SHAKES ❑
❑I.as owner of the property,or my employees with wages as their sole compensation,will do
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Proles-
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
improves thereon,andwho tloes 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 Contractor's License Law 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.
E]I am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
7y affirm under penalty of perjury one of the following declaration:
have antl will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building
as previdad for by Section 3700 of the Labor Code,for the performance of the work for which this �p
permit is issued. 22 011 0 0�0 seismic
❑ have and will the performance
Worker's Compensation Insurance,as required by Section 3700's DEC ( �`
the Labor Code,for the performance of the work for which this permit Is issued.My Worker's Total
Compensation Insurance carrier and Policy number are: r Y - t. -- i
Carrier 57�T� 'fNn!!) Policy No.'w{(L'- 77. -000/3((9 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C❑ I
(This section need not be completed i1 the permit is for one hundred dollars J$1 00)or less.) `
I certify that in the performance of the work for which this permit is Issued,t shall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali. All roots Shall 15e irispected prior to any roofing material being
forala. r installed. If a roof is installed without first obtaining an
Data/2' Z3-`G� Applicant �i•' inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate -xempllon,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Leh Cotle,you must forthwith comply PP P Y P
with such provisions or this permit shall be deemed revoked. source regulations.
I certify that I have read this application and stale that the above Information Is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spectionpurposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against lieblliiies, ;;R,
judgments,costs and expenses which may In any way accrue against said City in consequence IGNATUR A ICANT 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