R 5582 (2) APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5582
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
G Q
19'1 L OV• %,7_#, RESIDENTIAL " COMMERCIAL - OTHER
OWNER'S HAZARDOUS FIRE AREA
/t �j I I�Q YES ❑ If yes-I understand that a Class A
NAME D!1 r \c,7 Cly r' roof assembly is required.
C/�ILeNO Initial I.C.B.O.M
ADDRESS Par- - 5"5 M,v`. - 251C) S1Y(
k6k.0 +te EXISTING ROOF COVERING
PHONE C>2 ) — ( It, D NUMBER OF EXISTING COVERINGS '
CONTRACT(�.c_C•OR_'�SIr I �f
NAME � —+°�,Ka L ,. L_ )t/ Stn ,-k. S TO BE REMOVED_ TO BE RETAINED
S
ADDRESS � 7 2 , a ITYPE OF ROOF COVERING
CITY B ZIP
Q^ �]R EXISTING
PHONE 6633 1 T� ��T T BUILT-UP ROOF
LICENSE El NUMBER ASPHALT SHINGLES
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. p
C-3`i +C--20 �6 2 0 O WOOD SHINGLES ❑ e.'
License Class Lic.Number
Date 12. - -31- 99 Contractor h OTHER(SPECIFY)
OWNER-BUILDER UA�Tt Qc" c ❑
/
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,altar,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 provlelons W B
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the P
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 troll penalty of net more than five hundred dollen th wages
WOOD SHAKES DEC ,t %C'D
❑Lae owner structure
i not I my tended employeeswith (S e.7 Bole ssanCompensation,will s- �'W Ll
the work,and the structure le not Intended ores not for sale(Sec.7 Owner apply to an of property
and builds
or
improvessJons
The Contractors dLicense Law
orkhimnoorthroghhisownemployees,who rovidedaor WOOD SHINGLES C0 OF
Improves thereon,and who does work reefed or through his own employees,Improvement
that L
each Improvements are not Intended or offered far sale.If,however,the building or Improvement L4hl1(110 '
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.).
❑1,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors 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(e)licensed pursuer to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
E)I am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: / 1
❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compensation, 41 I J Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is Issued.
❑I have and will maintain Worker'.Compensation Insurance,as required by Section 3700 of '7 / Q 00 IS I
the Labor Code,for the performance of the work for which this permit Is issued.My Worker's I („— I�p )� `/�� Z 5
Compensation Insurance carrier and Policy number are: J 1 Total
tA10)t�- {-A"llr7L Policy No. 35 Z g 7 3 PERMIT AUTHORIZATION DATE
Carrier�n
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE NZQ
(This section need not be completed If 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 employ
any person In any manner so as to become subject to the workers'Compensation Laws of Call. All roots shGg be Inspected prior to any rbodiag material being
forma, installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understa d
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP will comply with all non point
with such provisions or this permit shall be deemed revoked. source regulations. -
I certify that 1 have read this application and state that the above information Is correct.)agree
to comply with all city and county ordinances and stale laws relating to building construction,and All cof.coverings I be cl s"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spectlon purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino epainet liabilities,
judgments,coats and expenses which may In any way accrue against said City n consequence, SIGNATURE OF APPLICANT ATE
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