R-7585 (2) PERMIT R-
APPLICATION
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APPLICATION FOR CITY OF CUPERTINO NUMBER 1 J 0 5
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
`{�� /Q� n
C � �sU 2e � 141_ /T V e RESIDENTIAL--X_COMMERCIAL OTHER
OWNER'S HAZARDOUS
p/ /J p fir^ HAZARDOUS FIRE AREA
NAME!✓" r� w^ Re-, �u-` YES ❑ If yes-I understand that a Class A
roof assembly Is required.
NO ❑ Initial
ADDRESS/ �V / GN/��f�Jy14ye /A T V e EXISTING ROOF COVERING
PHONE�O ! // J NUMBER OF EXISTING COVERINGS (4)
CONTRACTO
j) \
NAME ��S � TO BE REMOVED—, TO BE RETAINED
//�G W ( l '
ADDRESS �7(� Q� /' TYPE OF ROOF COVE I
CITY B Zip ill /�- `Yr✓ �� �(N v S k Y G x 4 q
d e A 3Q07 EXISTING U
PHONE��.i—�s(�-�ya29S BUILT-UP ROOF S
LICENSE /LCOS �, ASPHALT SHINGLES X
NUMBER `f✓
LICENSED CONTRACTORS DECLARATION
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 WOOD SHINGLES
License Class_SCs!(_ Li umber C"6 El
nd_ _ OTHER(SPECIFY) ❑
Dat Contractor
vNER-BUILDE LA nod PROPOSED
I hereby affirm Thal I am exe pt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Pro essions Coda: 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 Iherstrom 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($500).):
C]1, .SHAKES 1,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
improves thereon,and who does such work himself or through his own employees,provided that
such improvements are not intended or offered for sale.II,however,the building or improvement
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or improve for purpose of sale.).
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Lew does notPROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or improve;thereon,and who contracts for such projects
with acontraclor(s)licensed pursuant to th /actors License Law. PROVIDE F .IN$T TION SPE-4S.
❑I am exempt under Sec. .B 8 P.C.for this reason
0.
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION ���JQ�(J� /
hereby ad under penalty of perjury one of the following declaration:
C]
have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, � Building
as provided for by Section 3700 0l the Labor Code,for the performance of the work for which this
permit is issued. Seismic
D I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of �Q
the Labor Code,for the performance of the work for which this permit is issued,My Worker's
Compensation Insurance carrier and P cy number are: Total
Carrie-$fie ✓ Policy No/.126_1<5 __ ' / PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NCQ
(This section need not be completed it the permit is for one hundred dollars($100)or less.)
I certify that in the pedormance of the work for which this permit is issued,I shall not employ
any person in any ma ner so as to become subject to the Workers' ompensation Laws of call. roots shall be inspected prior to any roofing material being
fornix. installed. If a roof is installed without first obtaining an
Data Applicant NQinspection,I agree to remove all new materials for inspection.
NOTICE T6 APPLICANT: It,after making this Certifice a of Exemption,you should become A IIC nderst ds ill comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP
with such provisions or This permit sM1all be deemed rovoketl. SO a regulation
I certify that I have read this application and state that the above information is correct. `gree'
to comply with all city and county ordinances and state laws relating to building construction,antl Il roof cove O S� a er.
hereby authorize representatives of this city to enter upon the above-mentionetl property for im -
spection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabiliti
judgments,costs and expenses which may in any way accrue against said City in consaq ce S F .PLI A
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE �I INSP. DATE INSP, y t/ DATE
TEAR OFFI SPE,CTION: BATTENS: FINAL: C�
INSP. DATE ds NSP. DATE INSP__ —DATE v
N E: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY