R 5792 (2) PERMIT R_ 5792
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
• BUILDING ADDRESS 180 DAYS FROM LAST CALLED INSPECTION.
/a L 3 3 W RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ It as—I understand that a Class A
NAME root assembly is required.
NO ❑ Initial LC.B.O.N
ADDRESS— EXISTING ROOF COVERING
PHONE 53 NUMBER OF EXISTING COVERINGS
CONTRACTOR' -
{n/ yn !
'NAME TO BE REMOVED - TO BE RETAINED
J /��. �
ADDRESS YYQa K '20
D 1 1 TYPE OF ROOF COVERING
CITY a ZIP J Ind
7 EXISTING
lilleol 0.!�� g 3 0
PHONE�la SON l�`N -JS -.16 3 - 3 BUILT-UP ROOF ❑
LICENSE Z Ob
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby affirm inion that em si licensed under Professions
of Chapter S(commencing with Sectionnd WOOD SHAKES
7000)of Division 3 0l the Business and Proleselona Coda,and my license Is In full lone end �/
Liven WOOD SHINGL(^I ❑
License Claes Lic.Number �a /��
Dale Contractor E!00
❑ / rQ —
OWNER the Conn OECL License
��
I hereby affirm that em exempt from the Contractor's Licenea Lew for the following reason.(Sec.7031.5,Business antl Professions Cotle: Any city or county which requires a permit to �construct,alter,improve,demolish,or repair any structure,prior to Its Issuance,also requires the ❑applicant for such permit to foe a signed statement that he Is licensed pursuant to the provisionsor the Contracall;License Law(Chapter S(commencing with Section 7000)ofDivision 3 oftheBusiness antl Professions Cotle)or that he la exempt therefrom antl the basis for the alleged S ❑exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to ^ �xa civil penalty of not more thanpert Ilya by dredempl tlollsre th wag.): � C—O 6❑I,as owner of the property,or to employees with wepee as their Bole compensation,will do
alone
work,and the structure Is not Intended or offered for eels(Sec.7044,Business and builds
o-
Improvsth:Tho,Contractor'sawes such Lawdoes not or throuo an gh his
eof mployees,
whowrovidethat WOOD SHINGLES
Improves thereon,and who dose deco work himself or through els own employeae,provided reel ❑
such improvements are not Intended or offered for sale.ill however,me en of pr Of Improvement
notbuild
ld or I prove for purposetlaq the owner-builder will have the burden of proving that he tlld OTHER(SPECIFY) ❑
not builtl or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(SOC.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 contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sac. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty or perjury one of the following declaration: .-y .x
❑ have and will maintain a of thel Lab of Consent to performance
for Worker's Compensation,which
this ��1 I�� / BUi dingG (� O
as provided for by Section 3700 of the Labor Code,for the performance of the work for welch lots �k ✓!//
perm IS Issued. �cJ y Seismic /
have entl will maintain Worker's Compensation Insurance,as required by Section 3700 of
th Labor Code,for the performance of the work for which this permit is Issued.My Workers
Compeneatlo Insu ce riser and Pooicynumber are: o Total 0
Carrier & Policy Nb 7`—/ ,11PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If the permit Is for one hundred dollars($1 OD)or less.) Q ^. O q^ z y• 9
I certify that in the performance of the work for which this permit Is Issued,I shell not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell- All roofs shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Date 2.A3 Ak Applicant /� Exemption,p� p ' inspection,I agree to remove all new materials for inspection.
NOTsub ecctlt.the CE Wo k rs'C mpeT. lnsation provisions ofetheflcateLabofcMe, ou ustuforthwith lbecome
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 elate that the above Information Is correct,I agree
to comply with all city and county ordinances and state laws totaling to building construction,and All roof m coverin be class"C"or better. / _)
hereby authorize representatives of this city soler upon the above-mentioned property far In- /J spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said Clty In consequence
of the granting of this permit. URE COP AN
APPLICT DTE
• 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 /�—