R 5825 (2) ' PERMIT
5
APPLICATION FOR CITY of cuPERTINo NUMBER R- 582
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
- - WITHIN 160 DAYS OF PERMIT ISSUANCE OR
6
BUILDING ADDRESS 1B0 DAYS FROM LAST CALLED INSPECTION.
' \ \
O Z ( 1 Q V O RESIDENTIAL_/Z COMMERCIAL OTHER
OWNER'S - + C� .0 HAZARDOUS FIRE AREA
NAME i S I, UV O'C Vnel,�.4QA X`t
YES
roof assembly sirequirrednd that a Class A
C'. -.- ^ NO 71. Inti I.C.B.O.#
ADDRESS �1l4C_ EXISTING ROOF COMMING
PHONE Z NUMBER OF EXISTING COVERINGS QJ
CONTRACTOR'§0O�AI� TO BE REMOVED TO BE RETAINED
NAME t�III St)�'T�Q
CADDRESS
ITY&Z P 'C-'C) '�—b p TR Sa wn:;SOJ&9 91TYPE OF ROOF COVERING
EXISTING
PHONE -408' -5(S °l-1 3Z'I BUILT-UP ROOF
LICENSE (0 k 33 $ - C--3 ASPHALT SHINGLES
NUMBER
LICENSED CONTRACTORS DECLARATION '
I hereby affirm that I am licensed Under provisions of Chapter 6(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license le In lull force and
effect. WOOD SHINGLES ❑ j
License Cl�earp Llc.Number -1�
e 1-L1- �� ca IS OTHER(SPECIFY) ❑ ?ZL�_
Date Contractor
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 Ito 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 g(commencing with Section 7000)of Division 3 of the
Buslneas 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 lar a permit subjects the applicant to
e civil penalty,of not mors than live hundred dollars($500).): fill
E]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 allered for sale(Sac.7044,Business and Pfoles-
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.It,however,the building or Improvement
is sold within one year of completion,the owner-builder will have the but rden of proving that he did OTHER(SPECIFY) El
build or Improve for purpose of sale.).
❑I,as owner of the property,em exclusive contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Cade: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.
Owneram exempt under Sec, ,B a P.C.for this reason
owner Date
WORKERS COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
y
I hereby affirm under penalty of perjury one of the following declaration: `Y
❑I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, (�y( BUlldl
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this x ^ �f��
permit h v and API? 21 Seismic -1
have end will the performance
Worker's Compensation Insurance,as requiredsu d.My
Worker's's .l
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's C�ryOh � Total
Compensation Insurance terrier ann�d'Pollc numberer�a/: O/KR -H Sy3 f/ 1IL"
Carrier` Its r CSL DMd an
wMd/Policy No. 3 3 PERMIT VIIIJAVATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.[]
^ ,
(This section need not be completed 11 the permit Is for one hundred dollars($100)00)or less.) (�
1 certify that In the performance of the work for which this permit Is Issued,I shell not employ
any person In any manna,so as to become subject to the Workers'Compensation Laws of Can- All roofs shall be inspected prior to any roofing materiaging
fornix. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE a APPLICANT:Workers'
Compensation
after making this Certificate of oExemption,, ou ustuforthwllthbcompll Applicant understands and WIII comply With all non point
subject to the Workers'Com If,after
kinglons of the Labor Code,
PY
with such pramelpne or permit analr+be deemed revoked. I 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 stets laws relating to building construction,and All Of o ' gS bP`CIaS "Or baiter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
ep purposes.
We) ./�
(We)agree tos save,Indemnexpenses
and keep harmless the City of Cupertino y n c....liabilities....... ^—i)�//)
.1judgments,the gran coats and expenses which may In any way accrue against said Clry In consequence
of the granting of this permit. S ATURE OF APPLICAN DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. - DATE
TEAR OFF INSPECTION: BATTENS: - FINAL:
INSP. t DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY