R 5873 (2) APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5873
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
2 67-e✓eniS L-viypti 2y
Apr- SQ/ RESIDENTIAL COMMERCIAL OTHER
OWNERS HAZARDOUS FIRE AREA
- c 4 VES ❑ If yes—1 understand that a Class A
NAME V K f/ i //6/A.C.P rapt assembly is required.
No X
Initial LC.B.O.N
ADDRESS— Ion/ n �C2n//L llJLl/D LUPI gsoyy EXISTING ROOF COVERING
N/A FUSE COA17�C.aC7b2," NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOR'S ^ ^CONT C ./
!J f� _ / r' /1 TO BE REMOVED�L TO BE RETAINED
NAME �P AJA/S SAA/Cf° r10077—/N + ( QIAI�
ADDRESS TYPE OF ROOF COVERING
CITY B ZIP Z 2 9 z- L'ot�cp c-o .4✓ ST q,s-/zs EXISTING
pi
PHONE �D8r— �72� _ 00a�DeN/Se:. BUILT-UP ROOFLICENSE
❑ �v�
NUMBER J 7 �i�r `3/'3/
9 /9 ASPHALT SHINGLES ❑ fyQQ�S
LICENSED CONTRACTORS DECLARATION
I hereby affirm that em licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
70 0)of Division 3 0l the Business and Professions Cade,and my license Is In full force and
effect, L""I fZ
[-- ? WOOD SHINGLES ❑
License Class 3 Llc.Number J J
&PI¢e i � OTHER(SPECIFY) ❑
Date Contractor
NER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Conlmctors License lot the following reason.
(Sec.7031.5,Business and Professions Code: Any city Or ca y which requires a permit toor
construct,alter,Improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
Of the Contractor's License Lew(Chapter a(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 7'V
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 dollars($500).):
EJ 1.as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes.
sive Coda:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
❑
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sate.It,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did pR ❑
not build or Improve for purpose of sale.). OTH�W rPr'i�r�FY)
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Cade:The Contractors License Lew does not P DE X...13.0. REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects �g]��,QQrn
with a contractor(s)licensed pursuant to the Contractors License Law. PROV DE MF'GFY.1N$TALLATION SPECS.
❑1 em exempt under Sec. ,B 8 P.C.for this reason Ci I r
Owner oats
WORKER'S COMPENSATION DECLARATION APPLICATION DAT 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 aelbinsure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /
p
III leauoit C/,x�
heveend will maintain Workers Compensation l nsurence,as required by Setlon 3700 of r Seismic
L r Code,for the performance of the work for which this permit Is Issued My Workers / /70.'[
Comp etion Insurance carrier and Policy number are: ,(( Total ( /O J 0
Carrier -5x14--T'L 'E611p PolicyNo.`✓/�0�; PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.C] e-3',g
(This section need not be completed If the permit Is for One hundred dollars($100)or less.) ✓✓// �- T`
1 certify that In the performance of the work for which this permit Is Issued I Shall not employ ' CY Cl
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. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subject to theCE OAPPLICANT: If,after Worrkers'Compensation provisionsloftheficate of Laborr Code,Exemption,
must forthwithcecome
omplyApplicant understands and will comply with all non point
with such provisions or this permit shalgbe deemed revoked. Source regulations.
I certify that I have read this application and some that the Above IMormatlon Is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and - All roolorloverings tO bB ItEr
.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
election
n-
sp(W ) purposes. ks ��
(We)agree s save,indemnity and keep harmless the City of Cupst said Ci y n con liabilities,
judgments,coats and expenses which may In any way accrue against said City In consequence
oTthe granting of this permit. /SI�RIIATI IRE OF AP (CANT 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'
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