R-5473 (2) APPLICATION FOR CITY of cuPERTINo
NUMB PERMIRR- 5473
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (40$)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED ,
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S , HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Claw A
NAME ^CNV root assembly is required.
NO ❑ Inilial I.C.B.0.H
ADDRESS / Ce" EXISTING ROOF COVERING
PHONE (7 S `O Z NUMBER OF EXISTING COVERINGS I
CONTRAC 'S n
_ TO BE REMOVED � TO BE RETAINED
NAME 4e_kr%L_ G�6i
ADDRESS ' S s n� CI
`i t I S r3 P F V IN'
CINaZIP C. EXISTING
PHONE`S/off, 7o 6 — ?_53 :7 BUILT-UP ROOF Rri C'
LICENSE ��
NUMBER ASPHALT SHINGL S NOV 1997
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions 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 SHINGLE Y'
License Class 1 Up.Numbs!
Data �7 Contractor OTHER(SPECIFY) - ❑
OWNER-BUILDERDECLARATI PROPOSED P A I n
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 �p[prD
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions REEL
of the Contractor's License Law(Chapter B(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 No A P
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to 'Vif Urn 111NU
e civil penalty of not more than live hundred dollars(S500).): WOOD SHAKES
❑I,as owner of the property,or my employees with wages as their sole compensation,will do
the work,and the structure Is not intended or affered for sale(Sac.7044,Business and Profes- CI Vr V UrL-n I IMI
sions Code:The Contractor's License Law does not apply to an owner of property who bullas 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 �"1
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O. REPORT NO. d�
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractors License Law, PROVIDE MFGR. INSTALLATION SPECS.
❑1 am exempt under Sec. ,B a P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby allirm under penalty of perjury one of the following declaration: /ry
I have and will maintain a Certllicato of Consent to self-insure for Worker's Compensation, lf Building ( J
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
perm IS Issued. /l l)A7 �/r "J Seismic ' yo
have antl will mentsin Worker's Compensation Insurance,as required by Section 3700 of /
„ill Le or Coda,for the performance of the work for which this permit IS Issued.My Worker's Total ( 3
Company n Insurance rrle antl Poll number ere:
Carrier Policy No.O Z PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' /1 A
COMPENSATION INSURANCE N.O❑ —}') 6 V d �— Q ti
(This section need not be completed If the permit Is for one hundred dollars
(5100)or less.) J
I 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 in a kers'Compen Ion Laws of call- All roofs shall be inspected prior to any roofing material being
'orale installed. If a roof is installed without first obtaining an
Date /� )7 leg Applicant inspection,I agree to remove all new materials for inspection.
oshoulecome
subject to the OWorkers*Compensation proAPPILICAkT. It,after lvisionis ofethe flLabor Code,you must forthwitlhbcomply Applicant understands and will comply with all non point
with such provisions or this permit shallibe deemed revoked, Source regulations.
I certify that I have read 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 covenirmsto 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, r
judgments,costs and expenses which may In any way accrue against said City In consequence SIGNATOR F APPLICANT DATE
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 ___