R-5575 APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R- 5575
■�
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
. - MVS OF PERMIT ISSUANCE O
160 DAYS 1S
180 FROM LAST CALLED INSPECTION..
BUILDING ADDRESS
LtM G.
�JLJ� 7A RESIDENTIAL COMMERCIAL OTHER
OWNER'S I.C.B.O.
��( yry/I ,µ((
III
FIRE AREA _
NAM t 'Ty k�I 1 ' I U A root assembly is requined
�1 YES ❑ It yes—Understand that a Clan A
�—
ADDRESS 00 �19s;.1 h'�� ✓ 25/0 NO ��� EXISTING R
rvbal
PHONE O IMVS. NUMBER OF EXISTING C RINGS
CONTRAC.
NAME4. , (Y. ✓�I �j - TO BE REMOJED TO BE RETAINED
ADDRESS//'� — q_ TYPE OF ROOF COVERING
CITY&zlp671 / irli ova/ SnyiJasx.
r` Q� EXISTING
PHONE\ ✓� . .BUILT-UP ROOF . ❑
LICENSE
NUMBER LT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION -
I hereby affirm that I am licensed under proWelons of Chapter 9(commencing with Section AKES ❑
7000)of DMsion 3 of the Business and Professions Code,and my license Is In lull force antl,
Ilam. /r'l WOOID$tH -
Gcanse CI C "V LJc.Number Fvr'S/ ❑
Date 9— Contractor - OTHE. fC ❑
OWNER.BUILDER DECLARATIONPROPOSED
I hereby affirm that I am exempt from the Contractors License Lew fcr the following reason. i
(Sec.7031.5,Business and Professlona Code: Any city or county which requires a permit to -
conMrud,after.lmprom,demollsh,or repair any structure,prlorto its Issuance,alsorequirealhe BUILT-UP ROOF D
applicant for such permit to file a signed statement that he is Scensed pursuant to the pro dsbi P
' of the Contractors License Law(Chapter 9(commendrg with Section 7000)of Division 3 of
Business and Professions Code)or that he Is exempt Merefrom and the beals for the alleged ASPHALT SHINGLES ��P �1{C.II U
nT
exemption.Any violation of Sacdon 7031.5 by any applicant for a permit subjects the applicant to r
'e cMl Penahy of not more than five hundred dollars 15501).): WOOD SHAKES
❑I,es comer of the property,or my rnployees with"gas m their sole compensation,wip do !� ❑
the work,and the structure b rot Intended or offered for sale(Sec.70x6,Business and Profee- CITY l.11 (rl,.lf CYI I IIY�I
alone Cade:The Contractors License Lew does not apply to an owner of property who bubds or WOOD SHINGLES LJ
Improves Neuron,and who dose ouch work hi nm1f or through his awn employees,provided Nat
sum Improvements are not Intended or offered for sale.It,however,the building or Improvement
Is add mhin oro year of completion,the owner-0ullder will have me burden of prating that he did OTHER(SPECIFY) ❑
not bund or Improve for purpose of sale.).
❑I,as owner of the property,am exdul linty confirming with licensed contractors to construct
the project(Sac.701 Business and Professions Cade:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who foul ds or Improves thereon,enol who contracts for ouch proleota
with a contractor(s)licensed pursuant to the Contractors License Lew. 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 COMPENSATK)N DECLARATION
I hereby affirm under penalty of perjury one of the following dederatbn:
❑1 have and will malmon a Certificate of Consent to self-insure for Workers Compensation, Building
as prwlded for by Section 37W of the Labor Coca,for the performance of the work M ch this which
permit
F7I leve and q_�� �-7 Zzs- Seismic
❑ hwa and will maintainPerformance
Workers f Mew work
which MIS p required u Section 3700rs ,,,J
me Labor Cade,for cine performance d the work for which thU permit b Issued.I6Y Workers 1 Total
Camp Tion IncIu�r nce�rtdr e�PPolic/y�rly�maLe-r are
2
Garr (/,(/�1CL 1''�M/+�lAr I s 'Y policy No.')� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXE
ON FROM WORKERS'. 0111111
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If the permit is for one hundred dollars III or less.)
I cei Chet b the performance of the work for which thu permit Is mum,I shell M artploy
any person In any manner so as to become subject b the Workers'Compensation Laws of Cell- All roofs shall be inspecti prior to any roofing material being
fornia. installed. If a root is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT If,after making this Callficate of Exemption,you should become . A hcant understands and will comply with all non point
WNW to the Workers'Compenaetion provisions of the Labor Code,you must forthwith comply P P Y P
with such provisions cr this Permit ehalCbe deemed reviled. rCe regulations.
I pertly that I heve read this application end erne that the above Information Is correct.I agnea
to comply with all city and county ordinances and state leve relating to bulldlrg cpna;t=n,and All r Of COV rings 10 a SS"C"or Her.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,Indemnity and keep harmless the Dy of Cupertino against Ilabitldaa,
o�e ens,dcosng o and expanses which may In anyway aoaue against said City In consequence ffila permit. SI N UR O PPL NT DATE
r 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