R-5492 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR- 5492
INSPECTION DIVISION PERM IT EJ(PIRAFION
REROOF PERMIT (408)777-3228 PERMIT EXPUPIES IF WORK is NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1110 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
no RESIDENTIAL COMMERCIAL—OTHER—
OWNER's H�_�ADOUS FIRE AREA
NAME M 0 1 YES [I —`y_f-,;s=Zftzl a Clabsts A
NO D Initial— I.C.B.O.I
ADDRESS isbi Lo Ayi - EXISTING ROOF COVERING
PHONE - ?_52-- 3-19 S NUMBER OF EXISTING COVERINGS
CONTRACTORS TO BE REMOVED TO BE RETAINED
NAME C1-6&n.S TYPE OF ROOF COVERING
ADDRESS
CITY&ZIP- EXI ING
PHONE !qcEi`32-7,�44-��
BUILT UP ROOF
LICENSE
NUMBER Cj+-v �A: ASPHALT SHINGIl�S
ONTRACTORS DECLARATION
I hereby affirm that I am lorpardl under provisions of Chapter 9(commencing with seaon WOOD SHAKES JUL [a 1999
70M)of DMsIon 3 of me Business and Profesti Code,and my Icense Is In full ftirce and
effect. WOOD SHINGLE El
I-camse Class ia�) Up,Num bar ::jc_na D
Date -7 1-1 lc)�,) Connector tall'.2en-plit OTHER(SPECI ej
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from Me Caramtor's Ulcerate Law for ow ng Up- PROPOSED
construct,after,Impro",dernallim,or ra;peir my structure,pror to Its Issuance.else requires Me
applicant for such Permit to file a sugnea statement that he Is licensed pursuant to the provisions
Sec.7031.5,BuMness arof Profenisions Code! Any dy or county which requires permit to
BUILT-UP ROOF
of Me Contractor's I-conse Law(Chapter 9(commencin,=h Section 70DO)of DMsion 3 of the
Business and Professions Code)or Met he is exempt t eirefrom and the beat.for fire alleged ASPHALT SHINGLES
exemption.Any viclatIcin of t3ection 7031.5 by my applicant for a permit subjects the applicant to
a civil penalty of not more than fW hundred dollars($5D)).):
[11.as ownarr of Me property,or my employees with wag"as their sets compensation,will do WOOD SHAKES El
the work,and the saucturs Is act Intended or offered for sale(Sao 70�4,11,Businen and Fables.
sions Codo�The Coirtractor's License Law cioas net apply to art cryartar of property who builds or WOOD SHINGLES
ftn�s therecon,and who all such work him,It or through his own employeas, dad that
such mrscon"monts are not Intended or offered for sale.If,howeber,Me Wading or=ant
is Will within ona year of completer,Me owner-loullcor will lba,,e Me burden of prorfing Met he did OTHER(SPECIFY)
not build or InI for purpose of III
0 1.as owner of the property,am eactusnely contraeftni;with licensed contractors to construct
the project(Sac.7c,4,11,Business and Professors Coce:The Contractor's Ulcers.Law close not PROVIDE I.C.B.O. REPORT NO. aj 13 -7
apply to an owner of property who builds or limpro,es Maroon,and wric,contri for such pachei
Mth a licrenuutcl pursuant to the Gontractor's License Law.
E]I am exempt under Sao B&R C.for this reason PROVIDE MFGR.INSTALLATION SPECS.
Owner Date
WORKER S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm,under pensifty of pedury one of the following deabapalcn:
0 1 have and will matintain a Certificate of Consent to self-Inature for Workere Compensation, Building I? e7
as proyked!for by Section 3700 of Me Labor Code,for the performance of the work for which this Seismic
permit Is asuac.
b(I he"and MU maintain Wei Connipensaflon Insurance,"required by Section 3700 of
Me Labor Code,for the peffiamnrince of the work for which MIS permit to issued.My Workers
ComperIl Mer and Pat"number are: Total
Carrier PofcyNAL6vs�914--i PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPT10N FROM WORKERS'
COMPENSATION INSURANCE IN C'�
(This section need not be completed If the permit Is for one hundred!dollar I$ W) less.)
I partly that In the performance of the work for which this permit Is Issued,I shot not e7loy �-7
any person In any manner so se to became subject tothoWorkero'Compensuflort Laws of alk All roofs shall be inspected prior to any roofing material being
forms. installed. if a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all now materials for inspection.
NOTCE TO APPUCANT-. If,after making ths Certificate of Exemption,you shroxitid become
sublect,to the Workars'C�Ipehacstlbn proAtuctina,of the Labor Code,you must foritnefth cornply Applicant understands and will comply with all non point
with such proAsons or this parant shall tre dearrial reaolead. source regulatons.
I cerdfy Met I heI read this application small share that the aticne Information Is correct I agree
to comply with all city and county ordinances and state laws relating to building constn�on,and All roof coverings to be class 60ir better.
hereby authorize rapresainuithan,of this city to enter upm Me atorewi-memloned property Err In-
erection puriabses.
We)agree to ism,e, indamirity and keep harmless Me City of Cupertino a Inst labliffles,
SIGNATURE OF APPILVANT DATE
jud�mri costs and expenses which my In any way accrue against suad C11,rn
of t a grarding of this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSR_DATE INSP - DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSR-DATE INSP-DATE INSP.-DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY