R 5594 (2) PERMIT R_ 5594
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(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
/J/5-l RESIDENTIAL-A—COMMERCIAL OTHER
OWNER'S ^ - - HAZARDOUS FIRE AREA
� �/ -YES [:jIt yes-I understand that a Class A
NAME 0- �] �� - roof assembly is required.
NO ❑ Initial I.C.B.O.#
ADDRESSS�✓M/-.—/ EXISTING ROOF COVERING
PHONE 2 S 7 ^nnY b NUMBER OF EXISTING COVERINGS /
CONTRAC R'S
NAME
I�� - BE REMOVED TO BE RETAINED
KYR C+
ADDRESS' TYPE���4� /1 TYPE OF ROOF COVERING
CITY&ZIP rf- Uit.tM1. l a
11 �c I
PHONNWP y/�� �� O dy' BUILT-UP ROOF ❑
CENSE
NUMBER SJ�I�"35/ ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em 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 lull force and
Liter WOOD SHINGLES ❑
License Cl y � Lic.Number � 3 5 /- -
Date J Z� Contractor OTHER (SPECIFY) ❑
OWNER-BUILDER DECLARATN PROPOSED
I hereby a#Irm that I am exempt from the Contractors 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 El
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
• Business and Professions Code)or that he is exempt therefrom and the basis for the applicant
to ASPHALTSHINGLES
exemption.Any violation of Section hundred
by any applicant for a permit subjects the applicant t0
a civil penalty of not more then five hundred tlollve($500).):
01,as owner of the properly,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 Profee-
slons 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.ll,however,the building or Improvement A e b
is sold within one year of completion,the owner-builder wl 11 have the burden of proving that he did OTHER(SPECIFY) 1
not build or Improve for purpose of sale,). ❑
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct Q
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE W.B.Q. REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects A ! J)
with a contractor(a)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
C]I am exempt under Sec. ,B&P.C.for this reason
Owner WORKER'S COMPENSATION DECLARATION APPLICATI A L ATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: GI I C 41V V s•1't f B7U
❑I have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, DO Building ����
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this �� C/�� /
permit is issued. R l y� Seismic
[DI have and will maintain Worker's Compensation Insurance,as requl red by Section 3700 of / oO
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's If 1 a carrier
Compenae `rannd Policy number ere: ^ p Total
Carrier R.CLJ 77 /QLi PollcyNo. /l �e '��-3 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.1] � ?
(This section need not be completed If the permit Is for one hundred dollars(8100)or less.) ... sL..�
I certify that In the performance of the work for which this permit is Issued,1 shall not employ l
any person in any manner so as to become subject to the Wo re'cempeneaupn Laws of call- All roofs shall be inspected prior to any roofing material being
fornia' 12-411t
installed. If a roof is installed without first obtaining an
Date L 2'3 4 Applicantinspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: ll,after making Ihis Cmilli.mg of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Codo,you must forthwith 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 Mat the above Information is correct.l agree
to comply with all city and county ordinances and elate laws relating to building construction,and All roof covert t0 fie Class°C°Or better. -
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities, .Z. b
_ of he gaoling ofan is cost.tan d his permit.ee which they In any way accrue against said 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