R-5032 (2) PERMIT R_ 503
2
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 LASTCALLED INSPECTION.
BUILDING ADDRESS
IOfC07 /�?�— iro.c c ✓9, RESIDENTIAL V COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
�C ' YES ❑ II yeas understand that a Class A
NAME
roof assembly Is required
� NO El
Initial I.C.B.O.H
ADDRESS /o/67 �•s�.- /�yp�y �«/� , EXISTING ROOF COVERING
/ /
PHONE 73z,Or ZL NUMBER OF EXISTING COVERINGS
CONTRACTOR'So /
1' NAME /C..�yL �T.� rL ZiaG�f' TO BE REMOVED TO BE RETAINED
ADDRESS
_ TYPE OF ROOF COVERING
/b� Q _ / /<� /_ - /Qr'os f/3ra
CIN 8 ZIP UF'1GC /4dC4 7 �/O EXISTING
PHONE ii g 47/U BUILT-UP ROOF ❑
LICENSE 7� 2
NUMBER L`r/y''o ASPHALT SHINGLES
LICENSEDdunderCONTRACTORS DECLARATION S
hereby iaffirmnion that em Business
licensed under Professions
lone of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 0l the Business end Prolesslans Cotle,and my license is In full torte and p
enact WOOD SHINGLES
v+—'v+—' 74_0
License Class C Lic.Number / IFyY ^ fC
Date 7 y Contractor 4 ��� I�J OTHER($PECI �t7 ❑
/ �� 8
OWNER-BUILDER DECLARATION PROPOSED �(h V 1`996
I hereby affirm that I am exempt from the Contractor's License Lew lot the following reason. C,
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to "i
construct,after.Improve,demolish,or repair any structure,prior to its Issuance,also requires the BUILT-UP ROOF �7/y/f Elapplicant for such permit to file a signed statement that he IS licensed pursuant to the provisions U
of the Contractor's License Lew(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 El' exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than live hundred dollars($5001.): WOOD SHAKES El❑I,as owner of the property,or my employees with wages as their sole compensation,wilt do
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Proles.
slons Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑ �� .,r�yl'i
improves thereon,and who does such work himself or through his own employees,provided that Ly
such improvements are not Intended or offered for sale.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 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(See.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 builds or Improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION 1111`1 six
I hereby affirm under penalty of perjury one of the following declaration: /�'I
O 1 have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, 11vJ/tl�,b
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this B I
permit Is issued.ntl. Q Q� $ ISrnIC
I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of (� /
t L bor Code,for the performance of the work for which this permit Is Issued.My Workers C f�C1 Total
Compensation Insurance carrier and Policy number are: 3
Carrier v,� LU�9 Policy No. /`' PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NA.❑
(This section need not be completed if the permit Is for one hundred dollars($100)or less.) -
t' certify that in the performance of the work for which this permit Is issued,I shall not employ
any person In any manner so as to become subject to the Workers'Compensation Lews All roofs shall be inspected prior to any roofing material being
fertile. n installed. If a roof is installed without first obtaining an
Date D-V6 Applicantinspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: 11,after making Certificate of Exemption,you should become A licant understands and Will Com all non Olrlt
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P
with such provisions or this permit shall be deemed revoked. Source regulations.
I cerlify that I have read this application and Stale 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 COV SS"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, l/
• of the costs and
this permit. SIGNATURE
which may In any way accrue against said City In consequence SIGNATURE 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