R 5090 (2) PERMIT R_ 5090
APPLICATION FOR CITY OF CUPEFrIN0 NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(40$)777-322$ PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAYS PERMIT ISSUANCE OR
180 DAYSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
'( ;? ^( (J(, '��J�
,' " R? I I a 'u ✓�``" RESIDENTIAL COMMERCIAL OTHER
OWNER'S �p� (� // I, 1 y n HAZARDOUS FIRE AREA
NAME�rD—YN—L `�"` )MZ0W r 1 e ltS ASO ES ❑ roof assembly s1 requireand d ClassA
�./�/� �'//� /� NO ❑ Initial I.C.B.O.x
ADDRESS �`� ���- (�l�t-� EXISTING ROOF COVERING
U& tO@"- �. NUMBER OF EXISTING COVERIN
I
PHONE
CONTRACTOR'b 1938 Old Middlefield Way TO BE REMOVED TO BE RETAINED
NAME Mountain CA 94043-950-1
ADDRESS View, TYPE OF ROOF COVERING
CITU&ZIP
EXISTING
PHONE _ �� 4to — R4 2'2
LICENSE BUILT-UP ROOF
Q ! \
NUMBER 3 ( � �- 3 ASPHALT SHINGLES ❑ ��/�
LICENSED CONTRACTORS DECLARATION
1 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 Code,and my license Is In lull force and
effect.
WOOD SHINGLES P
License Class Do.Number
Date —1 0- Contractor D OTHER (SPECIFY) JUL 19 AT
OWNER-BUILDER DECLARATION PROPOSED �
I hereby affirm that I am exempt from the Contractor's License Law for the following reason, �l l l OC VUI'rnH
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to �d 1
construct,alter.Improve,demorah,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 provlelona
of the Contractor's License Law(Chapter 9(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 nor more than five hundred dollars($500).):
C]1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
sions Code:Tho Contractor's License Law does not apply to an owner of property who build.or WOOD SHINGLES
❑
improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt.under Sac. ,B$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:
❑l have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, /�/�r Building/22,
4
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this OVV g
permit is Code' Seismic
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of 7��`�
0 f7
the Lebon Cotle,for ins performance of the work for which this permit la Issued,My Workers
Compensation Insurance carrier and Polley number are: - / < �pyr�[ Total
Carrier�j�✓� policy No.ljl/�1QV RLdAZ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This eection need not be completed If the permit Is for one hundred dollars($100)or leas.) /ate
1 certity that In the performance of the work for which this permit is Issued,I shall not amvjoy
any parson In any manner so as to become subject to the Workers'Compeneagon Laws of Celh A r s Shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Data Applicant -7�c�t inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,alter making Mhls Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith 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 I have read this application and state that the above Information is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof covering to b Ie�s" "or better.
hereby authorize representatives of this city to enter upon the above.mentloned property for In..•
sp(We) purposes. �/ y'�'7
gme)agree to save,expenses
and keep harmless the City a against
Cupertino against liabilities, f � U(
judgments,costs and expenses which may In any way accrue against ealtl City In consequence SIGNATURE OF APPLICANT T DAT
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 - -