R 5816 (2) ' rti
} PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5 816
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 190 DAYS OF PERMIT ISSUANCE OR
190 DAYS FROM IAST CALLED INSPECTION,
BUILDING ADDRESS /�
11D CT, RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
Lr YE If yes ss-I understand that a Claw A
NAME SAM NTCO L-LNO roof assembly is required.
p /� NO ///LLL777 Inif s I.C.B.O.#
ADDRESS U040 TAZ.Nl3cW CT, f CIAfF-MJD 95bi4 EXISTING ROOF COVERING
PHONE Cy '2 1 NUMBER OF EXISTING COVERINGS
CONTRAtCT_OR'S t+
NAME-_LDS l'�q-[bS �FlPlli TO BE REMOVED TO BE RETAINED
CITYBzIP 1111 Sm=TFI AVE. r SQL-Mase- eA W//Z ADDRESS TYPE OF ROOF COVERING
EXISTING
PHONE (409) 358- 1233 BUILT-UP ROOF ❑
CENSE
NUMBER ''19$ ro - 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 Coe,and my license Is in full force and
effect. WOOD SHINGLES ❑
License Class C 319 Lic.Number 149531/6
Date -`' _146 Contractor I-OZ Gtil S QooFtAG OTHER(SPECIFY) ❑
OWNER-the Conn DECLARATION PROPOSED
hereby affirm that 1 am exempt from the Contractor's License Lew for the following reason.
ILY
(Sec.7ct,aft Business and Profedemolish,
or rep Code: Any city or county which ceq iresalso a uir s to
constapplicant
alter,Improve,to file signed statement
anystructure,prior license Issuance,also pu i.l the BUILT-UP ROOF
of the Contractor's for ouch permit a lila a signed r 9(comm tnci g ie h Sectio pursuant to the pro o f the
of the ssanPo License Lew(Chapter 9(commencing with Section 7000)of for the 3 0l the
Business and violation of Code)or thet he is exempt therefrom and the Beale for the alleged ASPHALT SHINGLES
a civil en.Anyviolation Section 7031Sbyany applicant for a permit subjects the applicant to
e civil penalty of not more than tive hundred
employees
dollars(h wage: ❑
❑Las owner tithe property,Is not i to dad or offered
wages(as Sec,their sole compensation,ssand
Pr fes. WOOD SHAKES
the work,and the structure la not Intended or oNeretl for sale(Sec,7044,Business ntl Profee•
.Ions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES El
thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.If,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,ars owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Cotle: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 �T�p
wlth a contractor(.)licensed pursuant to the Cantreefor's License Lew, PR AR��IVIrGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason
Owner Aare APP- T N D VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the fallowing declaration:
❑I have and will maintain a Certificate of Conant to sell-Insure for Worker's Compensation, 't Building
ars provided for by Section 3700 o1 the Labor Code,for the performance of the work for which thl. CITY UI- t u Cr1111 U g
permit Is Issued. Seismic❑ have ne will the performance
rmanWorkers f the work
for Insurance,ars required by d.My
Workers 0l �� ��
.the Labor Code,for the performance of the work lar which this permit Is laeuetl.My Worker's
-Compenaatlon Insurance terrier and Policy number are: Total
Carrier CAL. Comer Policy No. W11"11113155 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need not be completed If the permit Is for one hundred dollars($100)or leas,) _
I certify that in the performance of the work for which this permit is Issued,I shall not emny person In any manner so ars to become subject to the Workers'Compensation Laws of Ni!Cal- All roofs shall be inspected prior to any roofing material being
formic. installed. If a roof is installed without first obtaining an
Data I-10-118 Applicant esus+++ D� inspection,I agree to remove all new materials for inspection.
subject to the ICE Wor APPLICANT:
mpelneetle n provisions of ttheflcate of Laborr Code,you mustuforthwshoulltlhbecome 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 1 have read this application and state that the above Information Is correct.I spree
to comply with all city and county ordinances and state laws relating to building constructlon,antl All roof coverings to be class"C"Or better. -
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spectlon purposes. �/�7���
(We)agree to save,Indemnify and keep harmless the City of Cupertino against IIebllliles, gM
judgment.,cost.end..pensee which may In any way.cerue against said City In consequence SIGNATURE OF APPLICANT DATE
of the granting of thio 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