R 5784 (2) PERMIT
APPLICATION FOR CITY of cuPERTINO NUMBER R- 5784 .
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAYS OF PERMIT ISSUANCE OR
WI DAYSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS C�
/O Z ".� ! /44 7 � p/4 RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
yy14� G cy,1q YES ❑ If yes—I understand that a Class A
NAME roof assembly is required.
/ NO Initial LOBO.If
ADDRESS '3 pYM' ! /��`►�� EXISTING ROOF COVERING
PHONE ZSS' /lag 3 NUMBER OF 61STING COVERINGS
CONTRACTOR'S
NAME �nS9� f '7 TO BE REMOVED / TO BE RETAINED
ADDRESS 'pK�AK _, TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE NUMBER ZII�iSZ ASPHALT SHINGLES El
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
License Class Lic.Number 2/�6SZ
WOOD SHINGLES ❑
Date 5=22^98 Contractor 1 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 provlalons
. of the Contractor's License Law(Chapter g(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
e civil penalty of not more than five hundred dollars($500),):
1]1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
sions Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sola.If,however,the building or Improvement _
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sac.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractors)licensed pursuant 10 the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
C]I em exempt under Sec. ,B&P.C.for this reason
Owner oats
WORKER'S COMPENSATION DECLARATION APPLICATION DATE, 11 VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, s Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this �p �/ "p/�q'��` 1�
parmuialeeaed. �pY /�j�o Seismic
�a have and will maintain Werke e Compensation which
as required Issued.
d.Section Worker's VV
the Leber Code,for the performance of the work for which thle permit Is Issued.My Worker's tt U
Compensetibn Insurance terrier and Policy number are: ..I Or.
� VUr[r Total
i �l/yS
Carrier `�'" Polley No.2$S� 96 PERMIT AUTHORIZATION
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed It the permit is for one hundred dollars($100)or less)
I certify that In the performance of the work for which this permit is Issued,I shall not am toy
any person in any manner so as to become subject to the Workers'Compensetlon Laws of Cali- All roots shall be ins ec Ior to any roofing material being
brnia. installed. If a roof is installed without first obtaining an
Date 5'12-9 B Applicant x-4sL, 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 with all non point
subject to the Workers'Compensation provisions of the Lobar Code,you must forthwith comply PP 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 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.
spection purposes. A
(We)agree coals save,and expenses
and keep harmless the City of st said Ci against liabilities, AA-44—
judgments,
,6e/'s.�
. ofthe granting of this permit es which may to any way accrue against sold City In consequence 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