R-5820 +` PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R 5820
- - INSPECTION DIVISION I PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
a o a s V r.e 4q D r RESIDENTIAL k!!� COMMERCIAL OTHER-
OWNER'S HAZARDOUS FIRE AREA-
ll /M .Q2 h✓Ve S YES ❑ If yes—I understand that a Class A
NAME I
- roof assembly is required.
NO ❑ Initial I.C.B.O.tl
- En VVIR EXISTING ROOF COVERING
_ ADDRESS/
PHONE
NUMBER OF EXISTING COVERINGS '
CONTRA R'S -
NAME �'N� r•SS NCB koo-r1•Kpl TO BE REMOVED TO BE RETAINED
ADDRESS 'aae.) '1 Lj y�C OI V� �11/CS J dam/ TYPE OF ROOF COVERING.
CITY azIP i EXISTING,
PHONE 440 k— "-t--O6 0? BUILT-UP ROOF -❑
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION -
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES - El7000)of Division 3 of the Business and Professions Code,and my license Is in full force and
effect' WOOD SHINGL
License Class ��—QQ/ ��� �� �Llc.Nur ar
Date f^I SContractor iRCkiisse,Ki [-'*CIF KBOTHER(SPECT - ❑
OWNER-the Conn DECLARATION PROPOSED
hereby affirm that I am exempt from the e: Any city License Law for the following reason. -. /
(Sec.]0315,Business and demolish,
or rep Coda: Any ally or county which requires a permit to p
ID
spittle ct,alter,Improve,to fie signed statair eny ment that
prior to its Issuance,rsuant also to the
BUILT-UP ROOF �+ ~
applicant for such permit a flaw a signed statement that he Is licensed pursuant to the pro of the 7
of the Contractors License Lew(Chapter Bisex(commencing with Section 7000)of for the 3 0l the ,�.,r�C Il,'
Business and Professions Code)or that he is exempt therefrom and the basis for the king to ASPHALT SHINGLES �f' �[i.rR 1 d 1U1�•®
exemption.lAny ty of oat morel han Section ive hue 5 by any sapplicant for a permit subjects the applicant to
e dvil penalty of not more than five by empldredoyees
dollayees (h wage: WOOD SHAKES /�.�N
❑Irks and
er the structure
i not I tended oyeffered wages as(Sec.their Bole compensation,will s- y!q•I bllI,ch.k uej
the work,entl the structure is not Intended or offered for Bale n owner of Business and Profen-
alone Code:The,a Contractor's License Lew does not apply to an owner of property who provided
t or WOOD SHINGLES ❑
Improves thereon,end who does such work himself or through his own employees,improvement ant
such improvements withinonyeare not Intended or owner for sale.I(however,the buildingof pr or Improvement
1.n tOld build or
prove for 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
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who bunds 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 Sec. ,B 8 P.C.for this reason
Owner - Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
I have and will maintain a Certificate of Consent to self-insure for Workers Compensation, ` ///• Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 1,/� '{�1 ,
permit ued. 1cv\ 1111V1 Off/ Seismic
eve and will maintain roanWorker's f the work
for which this
as permit
by Section Worker's
of
the Leber Code,for the performance of the work for which lMs permit Is Issued.My Wgrker's - Total O
Compensation Insurance carrierand Policy umberare:
carder S �� PallcyNo.6/Nbo,42ro-3 PERMIIAURiORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) `
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 to the Workers'Compensation Laws of Call- All roofs Shall be/rispected prior to any roofing material being
forma. installed. If a oof is installed without first obtaining an
Data Applicant inspection,I gree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Cotle,you must forthwith comply
with such provisions or this permit shall be deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information Is correct.I agree All roof coverings to be class"C"Or better.
to comply with all city and county ordinances and state laws relating to building construction,and 9
hereby authorize representatives of this City to enter upon the above-mentioned property for In
ep wepurposes.
)
(We)agree to cave,Indemnifyand keep harmless the Cityof Cupertino against liabilities,
judgments,casts and expenses which may In any way accrue against said City in Consequence SIGNATURE OF 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY