R-5636 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER 8 5636
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT. (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
�- /o3Gy S��✓a ���
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
� YES FI 11 as—I understand that a Class A
t
NAME -%� /T� .of
assernbly is required.
// NO Initial LC.B.O.#
(7 LI EXISTING ROOF COVERING
ADDRESS 2
PHONE z�S�G73 NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S o /
NAME
,L Aecl Nt - TO BE REMOVED�TO BE RETAINED
ADDRESS /09 . _ /. ad.. , �pS CJS �fjo Or TYPE OF ROOF COVERING
CITY&ZIP 9�✓-�J
EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER N
7L �y ASPHALT SHINGLES ❑
• LICENSED CP AONTRACTORS DECLARATION ry� p
I hereby affirm that I am Ilcensed under provisions of Chapter a(commencing with Section WOOD SHAKES I)R
7000)of Division 3 of the Business and Professions Code,and my license is in full force and
affect.
WOOD SHINGLES
0,;;q
License Class Llc.Number 7Z � 'APR 24� lk rD �s
Data 97 Contractor 'e & OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION 011 OF LUPEHIINO
I hereby affirm that I am exempt from the Contractor's License Law for the following reason. PROPOSED
(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 Contractors 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 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 live hundred dollars 1$500).):• WOOD SHAKES
C]1.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 Profes-
sions 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.If,however,the building or Improvement
is sold within one year of completion,the owner-builder will have the burden of proving that he dict OTHER(SPECIFY)
not build or Improve for purpose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO. 7�
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.
• -71 am exempt under Sec. ,B&P.C.for this reason
Owner Dale
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: f�_�
❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, BUlldingl
s asp.ovided for by Section 3700 of the Labor Code,for the performance of the work for which this [.[/
perm ih issuetl. / /'�� Seismic
•'I have end will maintain Worker's COmpensetlon Insurance,es required by Section 3]00 of
r 1 L bor Code,for the performance of the work for which this permit Is Issued.My Worker's (�
ompensation�Insuraanccee carrier and Policy number are: I '"� Total
Carrier -- - - AU^' Policy No. s� �oG�o-�G PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the permit Is for one hundred dollars($100)100)or less.)
I certify that in the performance of the work for which this permit Is Issued.I shalt not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of Cali- All roofs shall be inspected prior to any roofing material being
fornia. '' A installed. If a roof is installed without first obtaining an
Date —ZI,1-9Applicant G GpOG/ inspection, I agree to remove all new materials for inspection.
NOTICE subject to theOWorrkelreCCompansafo making
ara isions of Certificate
elt bor Code,yo �staortnwithbomply Applicant understands andwill comply all non point
with such provisions or this permit shall be deemed revoked. CB regulations.
I certify that I have react this application and state that the above Information Is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All to to be 6'orbetter.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
apectlon purposes.
(We)agree to save, Indemnify and keep harmless the City of Cupertino against liabilities, T T
al ga g�enting of this pets,costs and PmlL as which may In any way accrue against said City in consequence $I URE 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