R-5902 'J
PERMIT
APPLICATION FOR CITY of CUPERTINO NUMBER R- 5902
.
INSPECTION DIVISION PERMIT EXPIRATI N
REROOF PERMIT (406)777-3226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
160 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
. t D7_`(
1q RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
T� . ._ _/�;r &Q ti-, ,,—'�E:z VES ❑ tl yes s I understand that. Class A
NAME r(�'�T�1l.CS Nil SIL. roof assembly Is required.
�r, � " NO FIIrtNal LC.B.O.tl
ADDRESSf �Vx-m Z Pb Lzs Am% (A 20 EXISTING ROOF COVERING
PHONE LV '-}�. 3Z1. NUMBER OF EXISTING COVERINGS y
CONTRACTOR'S "
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS /�f �' ', , 'l , �ffF ( �p(� TYPE OF ROOF COVERING
CITY&ZIP (-�4 ruj-A-z rVvL "• jP8sLt�
�A EXISTING
xe
PHONE FC-) BUILT-UP ROOF ❑ -
E
NUMBER ASPHALT SHINGLES ❑
NUMBEUJ
LICENSED CONTRACTORS DECLARATION
I hereby affirm Met I am Ilceneec under provisions of Chapter 0(commencing with Section WOOD SHAKES
71100)of DMelon 3 of Me Business and Professions Code,and my license Is In full force antl
effect' 1^ WOOD SHINGLES '
License Clew '-+�I Uc.Number Lyhl•� -) ❑
Date 0 r c(98 Com,redor OTHER(SPECIFY) ❑
OWNER-BUILDER DE RATION PROPOSED
hereby elflrm Nat am examen from the Cashed License Lew for the vires rg reason. j
(Sec.7031.5,Business and Professions Code: Arty,city a county which requires a perms to
conetrucL after,Improve,demolish,or repair any structure,prior to its Issuance,also requires the BUILT-UP ROOF
applicant for such permit to file a signed statement Net he Is licensed pursuant to the provisions
of the Contredafa License Lew(Chapter S(commeoclog with Section 7000)of Division 3 of the
' Buslnees and Professions Code)or that he Is exempt therefrom and to basis for Ne staged! ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a Permit subsets Me applicant to 717
a all penalty of net more Nan fire hundred callers($500).):
C]1,as owner of Me property,or my employees with wages as their We compensation,will do WOOD SHAKES
the war,,end Me structure rs rot intended or offeree for sale(Sec.7014,Bu mm aM Pmfes-
abrnCotle:The Connector.License Law does not appy to an owner of property who builds« WOODSHINGLES
Improves thereon,and who deals such work himself or through his own employees,provided that ❑
such Improvements are not Intal or offeree for vele.It,however,the building or Improvement
Is sole will one year of completion,the owner-builder will have Me bwNen of proving that he the OTHER(SPECIFY) Eln_of Wild or improve for purpose of sale.).
❑I,in owner of the property,em exclusively contracting with licensed contractors to consMxt
Me project(Sac.7044,Business and Professions Code:The Contractors License Lew deals not PROVIDE I.C.B.O. REPORT NO,
apply to an owner of property who outlets or Improves thereon,end who contracts for auch projects
wBb a contractors)licensed pursuant to the Contractors License law. PROVIDE MFCiR.INSTALLATION SPECS.
❑I am attempt under Sec. ,B&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 Cenlflcate of Consent to Bell-Insure for Workers Compensation, Building 7 Y o f e.
as provided for by Seddon 3700 of the Labor Code,for the performance of the work for which this 13.J l I /
D
hove
pal isissued. {�'/\ o
❑Ientl MIImaintain Warkera Congenma rttaa
Inaur ,asrequiredby 9eetbn 3]000) Seismic
the Labor Code,for Me performance of Me work for which Via permit Is laauetl.My Workers J(/ Q
Compensation Insurance carrier entl Pdicy number are 'T Total /�
Carrier PdicyNo.�7529PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPDON FROM WORKERS'
COMPENSATION INSURANCE 100)or Tj r /1 Tt
f1 Q
(This eecibn need not be compleioe N the permit Is for one hundred dollars($1 W)or lees.) 1 Vl
I certify that In the performance of the work for which this permit Is issued.I shall not employ
any person le any manner so els to become subject to the workers'Compo ntauon Laws of Call- All roofs shall be inspected prior to any roofing material being
famous. Lof U1�� installed. It a roof is installed without first obtaining an
Date ll Applmant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT:,after making this mncate of Exemption,youshouldbecome applicant understands and will comply with all non point
sub eat to Me Workers'Com nsetion provisions f the Labor Code,you must
with such provisions or this pendt shall be diesel reSource regulations.
I cmtlfy Net l have mad MIs application end Biala Mat the above Information is correct.l agree
to comply with all city and county ordinances and state laws relating to Wlltling conawctbn,aM All roof coverings class`s or better.
hereby euthoram representatives of Nle city to enter upon the above-menflonetl property for In-
spection purposes.
(We)agree to ease,Indemnity and keep harmless the City of Cupertino eaeinat liabilities,
Judgments,costs and expeneas which may In any way accrue against said City In consequence
of the granting of Mrs pormft, SIGNATURE 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