5335 (2)E,
OFFICE COPY
PERM R- 5335.
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
' 614?9 Ski KOV-D v'
RESIDENTIAL_Z�COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
�� / / AIVA)�
VES ❑ If yes I understand that. Class A
NAME 0 �l1
s
NO roof assembly is required.
❑ Initial I.C.B.O. #
/ pp
ADDRESS_(0 r�AGP /ci 00-0
EXISTING ROOF COVERING
PHONE —
NUMBER OF EXISTING COVERINGS
CONTRA R'S
NAME e
TO BE REMOVED ..5 TO BE RETAINED
ADDRESSM
TYPE OF ROOF COVERING
CITU 8 ZIP
,
d�[ O f&JEXISTING
PHONE 1[ 1 - /
BUILT-UP ROOF El
LICENSE
I
ASPHALT SHINGLES El
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license Is In full force and
WOOD SHAKES ❑
'
effect.
f�WOOD
Class � / Lic. Number -
Date LS_��—c%% ConiOTHER
SHINGLES ElC-3License
(SPECIFY) ��
OWNER -BUILDER RATION et�J in
hereby affirm that em exempt from the Contractors License Lew for the following reason.
PROPOSED
(Sec. i
Business and Professions Code: Any city or county which requires a permit to
construct, It
applicant, alter, h pmva, demoto file signed statany ement
structure, prior to Its issuance,pursuant to theprovirequires the
of br such permit flaw a signed statement that licensed pursuant m the pro
BUILT-UP ROOF
of the
the Contractor's a g it
License Law (Chapter 9 (commencing with Section ]000) of of the
3 the
ssanPo
Business entl Professions Code) or that he Is exempt therefrom and the for the le
for the alleged
ASPHALT SHINGLES ❑
je is
exemption. oft San fon h031.5 any for a permit subjects the applicant to
Sicant
e dull
civilpelty of
anally of not more than five by
more undred (Swag.):
, yeesdollars
❑I,es owner sthe property, employees
or oesred wages asthdrsole compensation, will do
WOOD SHAKES ❑
the work, and the structure Is not Intended
tI to ded offered for sale Buenas and Profes-
sions Cada: The Contractors License Lawdoesapply to or
do n owner of property es, whobuildsWOOD
thereon, and who does such work himself or through his own empbyees, Improve meet
hiso own
such
SHINGLES ❑
improvements
such Improvements are not Intended or offered for sale, It,ill however, the en of r or Improvement
Is e r of
provne
not or forpurposetofstheowner-0ulberwallnavetheburtlanofprovingthemhatlld
not build or Improve for purpose of sale.).
OTHER (SPECIFY) ❑
❑ 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 Lew does not
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who bulbs or Improves thereon, and who contracts for such projects
with a contractor(a) licensed pursuant to the Contractor's License Law.
I am exempt under Sec. ,B 8 C. for this reason
El P.
PROVIDE Ni INSTALLATION SPECS.
Owner Dame
WORKER'S COMPENSATION DECLARATION
APVbICATION DATE
VALUATION
PERMIT FEE
1 hereby affirm under penalty of perjury one of the following declaration: An
❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compensptlgp
'
as provided for by Section 3700 of the Labor Code, for the performance of the work for whic7T.1M3_
Y
Building �'
permit is issued. , /
I have %�
K
�,Qj.�
❑ and will maintain Workers Compensation Insurance, as required by Section 3700 of
Labor Code, for
Seismic
.the the performance of the work for which this permit is issued. My Worker's4(`
Compensation Insurance carrier and Policy number are:
(41 C�
Total
carriers- ddJ? .ALpn Policy No. Nl•3/�-GV
//jpERMITAUTHORIZATION
CE RTI FICA OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.E]
xis)
sisiDTE
(This section need not be completed If the permit Is for one hundred dollars (51 00) or less.)
771
1 certify that In the performance of the work for which this permit Is Issued, I shall not employ 1
All roof.^ shall be inspected prior to any roofing material being
any parson In any manner so as to become subject to the Workers' Compensation Laws of Call-
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, alter making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
Applicant understands and will with all non point
pp comply p y
with such provisions or this permit shalCbe deemed revoked.
source regulations.
I certify that I have reed 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 roof coverings to be class "C"or better.
hereby authorize representatives of this city to enter upon the above-menmaoned property for In.
spection purposes.
(We) agree to save, Indemnity and keep harmless the City of Cupertino against liabilities,
QJ
judgments, costs and expenses which may In any way accrue against said City In consequence
ATUREO 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