R 5936 (2) PERMIT R_ 5936
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1 S DAYS OF PERMIT ISSUANCE OR
• 100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
10 Z f?2- i77 RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
\ YES ❑ If yes—I understand that a Class A
NAME ALT 1 l� E—' roof assembly is required,
I� NO ❑ Initial I.C.B.O.N
ADDRESS L (2 X Z d - ,EXISTING ROOF COVERING
PHONE Lt to no _...
NUMBER OF EXISTING COVERINGS Y_
CONTRACTOR'S `^/
NAME CS I N�ii"rU�7.— e C I n\ l` 16 TO BE REMOVED TO BE RETAINED "A—
CADDRSSITY BEZIP Z l 'u L L T' ST �J -2—
7v) C�Jf , TYPE OF ROOF COVERING
q OF
EXISTING
PHONE.— 3 Cn� -- Ot I I � - BUILT-UP ROOF ❑
LICENSE
NUMBER I v - ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under previsions 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
effect. WOOD SHINGLES ❑
License Claes � Lic.Number 1 O
Dare (a -9P Contractorrlissltio- l/ OTHER(SPECIFY) ❑
OWNERBUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law 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 a(commencing with Section 7000)of Division 3 of the L7
• Buainass 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 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 Profen
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHIN8L6,�SI El
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-Wilder will have the burden of proving that he did OTHER/CQPECI ❑
not build 1aor Improve ler purpose of sexclu yy,E Q
❑oect(Se.704,Broperty,usies an Professions
Coely de: g with TheCsoensek's License
Law deals
�JE44
approject(See.]044,Business and ProrImprov Code:The and who con License Law doesnot PROVID B. RAR NO.
with y toac lit owner )property who pursuant
theC Contractors
tors Li,and who contracts for such projects (r�f
with a contractors)licenunder
a pursuant to the Contractor's license Lew. PROA1 V MI FGR:INSTALLATION SPECS.
I em exempt under Sec. ,B 8 P.C.for this reason
Owner oats
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penally of perjury one of the following declaration: �/
❑I have and will maintain a Certificate of Consent to selbinsum for Worker's Compensation, )(,�' r BUIId In C,f°.�
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 6-`-[-Cl� O `,
permit is issued. v (( V
E]I have and will maintain Worker's Compensation Insurance,as required by Section 3700 o1 f Seismic /110
—
the Labor Code,for the performance of the work for which this permit is issued.My Worker's Q
Compense�tplo Insurance earri1 antl Policy number are: /�� ('� / Total /��
Carrier 1..�{�I��A,//d1s &A— /4 Policy No.'lTy�`�' _xr-9 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ^ ` — ^�
(This section need not be completed If the Permit Is for one hundred tlollare($100)100)O or lase.) (SJ
I certify that in the performance of the work for which this permit is issuetl.16 not employ
any person in any manner so as to become au act to the Workers'Com eneetion Laws m Cali- All roofs shall be inspected prior to any roofing material being
ornia./ installed. If a roof is installed without first obtaining an
Data ""_ Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,after making t OnIfic.l.71 E. on,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation pot he f the Labor Cotle,you must forthwith comply PP p y
with such provisions or this permit shall be tl me revoked. Source regulations.
I certify that I have read this application en ate that rhe above Information IS correct.I agree
to comply with all city and county ortlinencel a ate laws relating to building construction,and All roof coverm s to be class°C°or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
Agol
oldthe pneni0^g of are pe.ponmult.es which may In any way accrue against said City In consequence ATURE LIC
r DATE
• PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP, DATE INSP. DATE
TEAR OFF INSPECTION: '7� PM BATTENS: FINAL:
INSP. DATE 7_7 INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY