R 5012 (2) PERMIT R_ 5012
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
1B DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/0�' Z o0e4^5r 14-t F Gv/`2F9rv0 9sb RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE ARE
.�' G- 7 YESJ If yes—I understand that a Class A
NAME --� t E�YtM.a w 11-� roof assembly is required.
NO Initial I.C.B.O.It
ADDRESS_/0�p-70 04X,4kx silt U/P&4tfAT1 �/y EXISTING ROOF `COVERING
PHONE POO 2'�3— /'979 - NUMBEROF XISTING COVERINGS `
CONTRACTOR'S
411 550"l
50" . /5 ;��� TO BE RE OVED TO BE RETAINED
1
J' NAME ••�' .X�"'
CITY&ZIP 3 Sy U.'r3�PIEe 0& S,e�Joy,9j7fZ TYPE OF ROOF COVERING
EXISTING
PHONE 972- yyss' BUILT-UP ROOFLICENSE
❑
NUMBER 7f &33
LIC .ASPHALTSHINGLES
LICENSED CONTRACTORS DECLARATION
91
I hereby affirm that I 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. 2 WOOD SHINGLES
License Class Lic.Number(3 00
Date Contractor 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 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($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-
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 ❑
such Improvements are not intended or offered for sale.II,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) El
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 tloes 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(a)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
E]I am exempt under Sec. ,B 8 P.C.for this reason
Owner Oere
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: p n u ��
❑ have and will maintain a of the
of Consent to performs for Worker's Compensation,which
this p 1f0�^lb aL 7/ /z�O Bull�IT7�.
as provided for by Section 3700 0l the Labor Cade,for the performance of the work for which Ihle " Yq " ,A xP V `O' T
permit is leauetl. - Seismic
El I have and will maithe pein Workeermancee f the work
for Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work lar which this permit is leauetl.My WorkeYs v
Compensation Insurance carrier and Policy number are: /1/✓G C-4A(/g 6 Total
Carrier CF��FORNxA 6WN? olicyNo.-0W9Lo13P:3 � 11y r PERMIT ` I ORIZATI DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.E] UrLn l l"" )
(This section need not be completed If the permit is for one hundred dollars($100)or lase.)
I certify that In the performance of the work lar 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 Cell- 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.
subject to
NOTICEthe WmkerePLICCompolneetlon,after makinprovisions of tthCerleflLaborr Code,of you mustufshoulbecome o thwith comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed 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.
epeWe)apurposes, \ s� `� GL _r .p`
(We)agree a save,Indemnexpenses
and keep harmless wa the City ai Cupertino y in con liabilities, 5�.�1'�y�` l'O
jud merle,conte end expenses which may In any way accrue apelnel mltl Clry In consequence
of tRe granting of this permit. SIGNATURE OF A ANT 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 _ . k Y .