R 5136 (2) PERMIT q. 513 6
APPLICATION FOR CITY OF CUPERTINO NUMBER
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 A
I J Q J
O Sl_I 0 RESIDENTIAL COMMERCIAL OTHER
OWNER'S ' HAZARDOUS FIRE AREA
NAME J O I` VES ❑ II yes-I understand that a Class A
roof assembly is required.
NO Initial I.C.B.O.g
ADDRESS A/SS'7 o sm?R O €XISTINGROOFCOVERING
PHONE -/ p2 6-6 NUMBER OF EXISTING COVERINGS
CONTRAPIQILS
NAME TO BE REMOVED TO BE RETAINED
ADDC CITYR&Z P d , 5pX J.G ' A l ow—s Gilar -
EXISTING
PHONE 3oQ 3835 BUILT-UP ROOF
LICENSE
NUMBER ASPHALT ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby alllrm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
enact. WOOD SHINGLES ❑
License Cleea C�3 7 Llc.Number^M7-��(`3f�I _
Date xs�7 ConlraCtorJ�. r1t._7!a ��wwk/ OTHER(SPECIFY) ❑
OWNER-BUILDER DECILARATIto LI - PROPOSED
I hereby aXlrm that I am exempt from the Contractor's License Lew 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 0(commencing with Section 7000)of Division 3 of the
• Business and Professions Coda)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 civil penalty of not more than five hundred tlollare($500),): WOOD SHAKES
I,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 Praise-
alone 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.If,however,the building or Improvement
Is said 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,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew 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 Lew, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: -
❑I have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, �O s - Bull
as itletl for by Section 3700 o1 the Labor Code,for the performance of the work for which this
Is" permit Is Issued. SEP 5 1996 sets to
j C]I have and will maintain Workers Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit Is Issued.My Workers
Compensation Insurance carrier and Policy number are: ( III V I' L Ut ..t r I utJ Total
Carrier Policy No. PERMIT AUTHORIZATION. /DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the permit Is for one hundred dollars($100)or lase.)
I certify that In the performance of the work far whit 1}r4 perm It le le u e�hall not employ
any person In any manner so ea to become subject t , orkers'c el�na fon Laws of can. All roofs s all be inspected prior t ny roofin material being
fornia. installed. If a roof is installedithout first obtaining an
Data r' Applicant inspection,I agree to remove all ew materials for inspection.
NOTICE TO APPLICANT: If,atter mekin aertllicate of Exemption, a Id become Applicant understands and will comply with all non point
subject to the Workers'Compensation pravl one of the Labor Code,you et f with comply PP P Y P
with such provisions or this permit shall be deemed revoked, source regulations.
I certify that I 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 construction,and All tooerin to be class"C"or bett7-i
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spectlon purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against Ilabllltles,
judgments,costa and expenses which may In any way accrue against said City In consequence
of the granting of this permit. URE OF ANT E
• 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