R-5276 PERMIT
APPLICATION FOR CITY of cuPERTINo
NUMRERR- 5276
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 18D DAYS OF PERMIT ISSUANCE OR
18D DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
V 0. rL'� ��^ RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME V/^I+ I 9 O r 1 YES E] tl yes I understand that a Class A
roof assembly Is required.
1 No ❑ IrYgal LC.B.O.tl
ADDRESS��� 1 a Tan 1 ( s— Ay P. EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS f
CONTRACTOR'S ('� � n ��-•
NAME
R7[S"S CiUA J7-X Rc�6T�Y'1 G. TO BE REMOVED TO BE RETAINED ..
ADDRESS TYPE OF ROOF COVERING
CITY szip '1 un \J 0.n LV4(0 OS
.5 w YN J,0 -5 , Cera `15 I Flo EXISTING
PHONE BUILT-UP ROOF q
LICENSE n���////�IIl^���,,f'
NUMBER ASPHALT SHINGLESEJ( '�
LICENSED CONTRACTORS DECLARATION ��IuU1 CCCCCCYY ED
I hereby affirm that I am licensed under provfamns of Chapter 9(commencing with Section WOOD SHAKES OOO
]ODD)of omsion 3 of the Busumssertl Professions Code,and my liberal is in lug force end
effect. bOfoII WOOD SHINGLES ❑
License Ga3�
ss Dc.Number V5O
Date Contractor OTHER(SPECIFY) �j ❑
OWNER BUILDER DECLARATION PROPOSED
hereby affirm Bu that am exempt from the Contractor's orUcamaecoup Lew for the requires
ng reason.
(Sec.7031.5, ,improve and Professors Code: Any dry or county which requires a permit si
construct,ensu,Improve,demela s n repeat my structure,prortoliven Its Issuance,also reproves the 'BUILT-UP ROOF I I )
applicant Ce for such Perth to flaw s(Chapter
r statement that he Is Isnand pursuant 0DO)of
the n 3 of the
d en Contractor's cal ee Law(Chapter 9(commandog with omSectionand 7000)of for the 3 0l the
exemption.
and Prdessbru Code)or that he a exempt applicant for
ra end mw heels for the applicant
to ASPHALT SHINGLES p�
exemption.Mof of ore hadbn hundred
tryany epd00).): epennitewlecte the epolunt to A
e clvll penalty of cwt more then five huntlred dollen($3001 J: 00AW,0
❑I,an owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES Clthe work,end the structure Is hot intended or offered!for sale(Sec.70".Bustnes,al Proms- CI I Vf
sbru Cade: The Contractors License Lew does not apply to an owner of property who buries or WOOD SHINGLES
Improves Thereon,surerwho doea,uch wvrk himself or through his own employees,provided that
such Improvements ere nor Intended or offered for Bele.If,however,the bulltling or Improvement
Is add wiWnone year of completion,the owner4 11der will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of elle.).
❑I,as owner of the property,am exclusively contmcdng Mtn licensed contractors to constnlct
the protect(Sec.704,1,Business end Professions Cade:The Contractor',Dense Lew does not PROVIDE I.C.B.O.REPORT NO.
aptly to an owner of propend who bullas or Improwas thereon,and who contracts for such projects
Mtn a contractor(e)licensed pursuant to tate Contractors license Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B&P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I heraby affirm untler barely of perjury one of the Idlowing declaration: '
❑I have and MII maintain a Certlfk:ate of Consent to sell-Insure for Workers Compensation, �J W
as Provides for by Section 3700 of the Labor Code,for the performers of the work for which this I si a O S' O U O Building/
permit is Isal l
❑I here antl will maintain Worker's Compensation Iruwrance,u required by Section 3700 of Seismic
Ne Labor Code,for the performance of ins work for which lfis permit Is issil y Workers
Go p\eru,a\tkm Insurers cenkr end Pdlry number are: Total
Canler`enL C�05ab�,)C� �e 4�e.aaa" moa
PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMCOMPENSATION
TIONINSURANCE
FROM WORKERS -
CpAPENSATION INSURANCE N.C{]
(This section need not be completed it tate permit is for one hundred dollars($100)or less.)
I carilfy that In the performance of the work for which thoe permh Is Issued I shell not employ C- J
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell- All roofs shall be Inspected P or to any roofing material being
fornix. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTIsugeect too En Workers'OompensaHon provIf,after bl nis CortIfficate l of me Labor of
yExamyou you
tfonnwlith comply Applicant understands and will comply with all non point
with such prwlslons or this permit all be deemed revoked. SO egulations.
to oa�ly with allrcity anEdwunrybiences and ttemllaws retail n buldinng con, a'6.an"d roof verings to be Gas C"or better.
hereby euVgrize representativee of this city to enter upon Ne above-mentioned property for In. N —
spectloo purposes.
(We)agree to save.Indemnity and keep hamdeae the City of Cupertino agatrut IIebIIMee, 10 P
r judgments,coats ane experue,which may In any way accrue egamat,add Clty In consequence S U E of PP N ATE
Of the granting d 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 ACCESSTO'ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY J