R-5869 PERMIT
APPLICATION FOR CITY OF CUPERTINO . NUMBERR_ 5869
REROOF PERMIT. IN PECTION(408)777.3228 PERMIT EXPIPAWOMii 1
(408)777.3228 WITHIN
EXPIRES80MYO WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
' 180 DAYS FROM LAST CALLED INSPECTION.
Will BUILDING ADDRESS '
0/00 IQe 0117v?-1t ' //
RESIDENTIAL COMMERCIAL______1L�.OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ II yes—I understand that a Class A .
NAME y Fan Ag mof assembly is required. .
NO ❑ - Initial I.C.B.0.11
ADDRESS 62. 1 EXISTING ROOF COVERING
PHONE — 3 NUMBER OF EXISTING COVERINGS
CONTRAC 'S
NAME N �+� - TO BE REMOVED�TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY&zIP�/8'z - ILbui �sd¢n�G1 �Tl/«J XI
P t. ?ye3
STING
PHONE 650 W'-61111 BUILT-UP ROOF El
NUMBER Oaffy.9b ASPHALT SHINGLES ❑
LICENSED CONTRACTORSsof Chapter
9(N
hereby effinn that am licensed under of Chapter I(commencing with Settlors WOOD SHAKES
7000)of DNIsion 3 of the Business and Professions Coca,end my license Is In lull force arM
effect.
WOOD SHINGLES ❑
Llcensa Cleve_1.. ` Uc.Numbor
Data �a-aa'ys Corm, pr f�SP. OTHER(SPECIFY)
OWNER-BUILDER DECLARATION D'JSI r PROPOSED '
I hereby affirm that I em exempt from the Contractor's Dcense Lew forth Idlowlnp meson.
(Sec.7031.5,Business end Professor,Code: Any dry or county which requires a permit to
caetnaH,eller,Improve,demolish,or repair any structure,pinor to Ile Isf u mbe, requires th
also e BUILT-UP ROOF E-1 .f
swil ni for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors I-cense Law(Chapter 9(commencing wIM Section 7000)of Division 3 of um
m;
Business and Professions Code)or that he Is exempt therefroend urs baste.for the staged ASPHALT SHINGLES El exemption.Any violation of Section 7031.5 by any applicant ick a permt subjects the applicant to
e dull penalty of nor more than five hurdred tldlam(SSW).): 1.�—
❑I,as owner of the property,or my employees with wages as their sale compensation,will ce, WOO sl ❑
the work,and the structure fe not intended or offered far sale(Sec,70",Business and Pause-
1998
Code:The Cantrectore Lienee Lew does not eppty to an owner of pmpeny who bWlds or W OD SHINGLES
Improves themon,and who does such work himself or through his own employees,provkied that `1 3 1998 ❑ A� '
such Improvements are
not Intentled or offered tar eels.I(however,me Wlltllnp or Improvement I U L LA
le said
within one year ofwmpetbn,the owner-builder will have the Wrticn of proving that he did Q ;IER SPECI Y`—
rot bulld or Improve for wrpose of sale.). (
❑I,eeownorofthsproperty,amexclueivelycantmcb Mmllcene9d conireclors to construct
the protect(Sec.70/4,Bualneee and Professions Cade:The Contractors Lienee Lew dose note I'�V�IDE LC.B.O.REPORT N
apply to an owner of property who bulltle or Improves thereon,end wino contracts for each projects
wlMecantmdoge)ucaneetl pursuant to Me Contractor's ucenae Law. PROVIDE MFG R. IN ST NSPECS.
❑I am exempt under Sec. ,B a P.C.for MIs reesa
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
'
I hereby affirm untler penalty of perjury one of the Mlowing declaration:
❑I have entl MII maintain a Cenlfkmte of Consent to salbinsure for Workers Compensation, Building
a5 provi letl for by Section 3700 of the Labor Code,for the pedormerrce of the work for whk:h this
permit is Issued.
❑I have end will melntaln Workers Compeneetion Insurance,as required by Section 37W of / /'2 Seismic
the Labor Code,iur Me performance of are work for whk:h this permit Is Issued.My Workers -73.?R
Compensation sursnce carrier and Polk:y,number are: Total Z
Carder — Policy No.u�L-v� /(�aCaJil PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(This section neeo act be wmpleted lf Me permit Is for one hundred dol($100)or baa.) 9
I canny that In the performance of the work farwNch this permit Is issued,I shell not rani
any person In any manner so as to became wbjen to me workers'Campeneatbn Laws of Cell- All roofs shall be inspected prior to any roofing material being
fomla. installed. If a roof is installed without first obtaining an
Date / 'n2 in Appllwnt ZXp- inspection,I agree to remove all new materials for inspection.
NOTI E TO APPLICANT: If,after making Ie Cenlficate of Examatlan,you should became ,applicant understands and will comply with all non point
eub)ect to the Workers'Compensation provisions of the Labor Code,you must fonhwith comply
with such provisions or this pal shi lfjba deemed revoked. source regulafions.
I canlfy,that I have reed this epplicetlon and Mate Met the some Information Is correct.I agree
to comply wIM all city and county ordinances and state laws releung to building const.,mon.and All roof Coverings to be classi or better.
hereby authorize represenmthres of MI5 dry to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,Indemnify entl keep harmless me City of Cupertino against Ilablliflee,
lutlgmenti,coats and expenses which may In any way accrue against said Dry In mruequenw
'cu Its s=11 mMie permit. I'NATU RE 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