R-5821 PERMIT
FOR Ciro of CUPERTINO, NUMBER'APPLICATIONR" 5 8 21
:1
INSPECTION DIVISION PERMITcPIRAn
REROOF PERMIT '(408)777-3228 _ PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
-'• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS , /
7 6 ¢
-7 r f/ I ISS—D✓) e . D kRESIDENT AL V COMMERCIAL OTHER
OWNERS HAZARDOUS FIRE AREA
M M �-u met r YES ❑ R yes-I understand that a Class A
NAME - roof assembly is requtred. -
.' 4.4 IC Q d d l'ik q K G) No ❑ Initial I.G.B.o.e
ADDRESS d EXISTING ROOF COVERING
PHONE -1 &— .337 1-3 -7 a),-7 NUMBER OF EXISTING COVERINGS
-
CONTRA TOR'S
NAME ham^(-S SGS K GP., T� - TO BE REMOVED I TO BE RETAINED ADDRESS
LI ✓�CO � � , .S J, �I SI� � - WW,
brry s ZIP EXISTING
PHONE6^
BUILT-UP ROOF
LICENSE
NUMBER ASPHALTSHINGLES ❑
-' LICENSED CONTRACTORS DECLARATION
I hereby arfinn that I em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
70DO)of DMison 3 of Me Business,and Proleselons Code,entl my license Is In full force and
affect' C S d S13WOOD SHINGLES ❑
Ucense Class Uc.Number
.Date I�� , � Doniracmr OTHER(SPECIFY)
P !�]� �
OWNER-BUILDER DECLARATION .A Af(JryW1D
p
I hereby affirm that I am exempt"In the Contractors License Law for Me following reason. l 15
(Sac:]031.5,Business and Professions Code: Any city or county which requires a permit to �r1�
construct,alter,Improve,demollah,«repair any structure,prbIssuance,also Its Issuaalso requires the BUILT F
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions (� [ I4��h
of the Contractors License Law(Chapter 0(commencing wild Section]1X10)of Division 3 of the y(TY1Q1 .�/I,Jetlrl hl�Q
Business and Profeselfn.Code)or that he Is exempt therefrom ark the beers for the alleged ASPHALT SH E ❑
exemption.Any vloladon of Section 7031.5 by any applicant for a permit subjects the applicant to
edull,analtys ow er not more Man Ilya hundred
yempl dollaye" (h wag): WOOD SHpI�Eg ❑
❑I,as owner of the property,or my employees with wages es their sole compensation,will do fC�(`i/
me work,entl to ihucture Is not Intendetl or offered for erre(Sec.]044,Business,and Prcfes- '
sons Code:The Contractor's License Lew doe.not apply to an owner of property who builds or WOOD SHIN L�/ ❑
Improves thereon,entl who does such work time or through his own employees,provided that Tzz
such Improvements are not Intended or offered for sure.If,however,the bulking or Improvement p/s r PI- V(,II
Is sold withln one year of completion,Me owner-bullder will have the burden of proving that he did OTHER(SPECIFY)
not build or Improve for purpose of vele.).
❑h as owner of the property,am d Professions
Code:
o e:T elm ntracetl contractors to construct i
the project(Sac.7044,perry h end Pror roma sthe:The Coniraacom commode
Lew tl projects not PROVIDE LC.B.O.REPORT NO.
apply to c an owner )properly pursuant
t or lmprovee thereon,entl wit°contracts for such projxts
wlma am exempt under
to Me Contrectors ucenee Lew. PROVIDE MFGR. INSTALLATION SPECS. -
❑I em exempt untler Sea ,B 6 P.C.for ihl9 reason
Owner - oats
WORKER'S COMPENSATION DECLARATION APPLICATION DATE -VALUATION PERMIT FEE
I hereby affirm untler penalty of perjury one of the following declaration:
•, ❑1 have and will maintain a CerWlcete of Consent to self-Insure for Workers Compensation, BUIldIng
es provided for by Section 3]00 of the Labor Code,for the performance of the work for which thla �� ' , I .25D
permit Igiecuad. - a/.`/.r_ Seismic
a entl will melnmin Worker's Cortpensetlon Insurance,as roqulretl by Section 3]00 of /I
_ the Labor Code,for me performance of the work for which MIs permit Is esued.My Workers
CompeneeIf Ina rence__W and Poicy number are: Total
Cartier r-VN a Policy No.PQ (N 00i PERMIT RIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE IIN GE
(This section need not be completed If the permit Is for one hundred dollars(5100)or .) - r!
I certify mat In the performance of me work for which cols permit Is Issued,I shell :1093,o)
any parson in any manner so as to become Subject to the Workera'Compensation Laws f Cao- All roofs shall be inVected prior to any roofing material being
Ifmla. - installed. If a,r941 is installed without first obtaining an
Date Applicant inspection,I agliffe to remove all new materials for inspection.
NOTICE TO APPLICANT:A-after making this Cartglmte or Exemption,you should become Applicant understands and will with all non
subject to the Workers'CompeneeNon pprovismna of the Labor Carl you must lordmid comply pP Comply P Y int
with such provisions or Ws permit shel.be tleemed revoked. source regulations.
I partly that I have read title application and state Mat Me above Information Is conect.I agree
to comply Mm all city ark county ordinances and spite laws relating to building construm'on,entl-'' All roof Coverings to.be Class°C"or b tier
hereby authorize repreeenmtives or rale city to enter upon the above-mentioned property for d- ' r
specton purposes. &
( -, (^• ISI \.
(We)ogres to save,Indemnity and keap harmless the City of Cupertino epelrut Ilablitrea, - ►I_� ~1�'- � •Y
Judgments,poste and expenses which may In any way amus against saki Chy In consequence
unite granting of rae pe colt. SIGNATURE OF APPLICANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP, DATE INSP. DATE
TEAR OFFINSPECTION: �G BATTENS: - FINAL:
INSP. •TaO DATE INSP. DATE INSP. DATE -
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY