R-5585 PERMIT
APPLICATION FOR CITY of CUPERTINO NUMBER R' S 5 8 5
r� INSPECTION DIVISION PERMITEXPIRATION
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
Qui\.�Q D
RESIDENTIAL--)(—COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE
AREA
_ _I' n/ YES ❑ Ifyes-IunWendthatClA
NAME .roofas y,isrea .
C/ AVO Initial EC.B.O.
ADDRZSID N
EXISTING ROOF COVERING
ES rx;7 .7iCUGViS �-f�lJ� (�
PHONE NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
.�y - /)^` �1 �/, TO BE REMOVED TO BE RETAINED
NAME�.(`I.y'1 , "7 r cW f f1G � /T'l ( S�/4��
ADDRESl
TYPE OF ROOF COVERING
CITY a S f PC
L/ EXISTING -
PHON ,� f o 1�- 7 BUILT-UP ROOF
LICENSE 1 .
1
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby allirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
El]000)of DIMelon 3 of Me Business and Professions Code,and my license is in full torte and '
effect. n AWOOD SHINGLES ❑
License Clase��2o tl Lic.Number -�n2,011) Ill
11�f Pl 4%A_ THER(SPECIFY) ❑
Data W11!_11 Contractor O
OWNER-BUIL DER DECLARATION ^ ED
I hereby affirm that I am exempt from the Contractor's License Lew for the following reason.�G.
(Sac.]031.5, Business and Professions Code: Any city or county which requires a permit to iC.
construct,orafter,such
Improve,demolish,or repeat eny structure,prior to a Issuance,also reproves the a!LT-UP ROOF
applicant for such permit to file a signed statement that he Is licensed pursuant al the requires
provIslons /�
of the Contractors License Law(Chapter 9(commencing with Section]000)of DNlslon 3 of the.
Business and Professions Code)or Met he Is exempt therefrom and the basis for Me alleged �O ASPHALT SHIN ❑
• exemption.Any vloletlon of Sectlm 7031.5 by any applicant for a permit subjects Me applicant to .
a cfvll penalty of act more than INa hundred dollars(5500).): WOOD SHAKES
❑I,as owner of Me property,tinny intended
employeeswithwages as their sole compensation,will e-
to work, ow er structure er not intended or ees wit for sats(Sec.it abl Business entl Profen- lV/
wens Code:The Contractors Ucense Lew does not appy to an owner of property who builds of
Improves thereon,and who does such work himself or through his own empbyaes,provided Mat WOOD SHINGLES
such Improvements are rot Intended or offered M eels.If,however,Me building or Improvement
lesoldwlMlnoneyearofcompletion,theowner-bullderwlllha,etheburdenofarmingthathedid OTHER(SPECIFY)
not buiid or Improve for purpose of sale.). _
❑I,as owner of the property,am exclusively contracting with licensed contractors to cor stntct
Me project(Sec.704q Business and Professions Code:The Contractors Ubenas law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who Dui ids 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 urMer Sec. ,B&P.C.for MIs reason -
owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
l I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain s Carifirab of Consent b"if-insure for Worker's Compensation, - B
as provided for by Section 3700 of the Leber Code,brine performance of the work br which this
permit is issued. ^ Seismic
❑1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of Cl_ �Z �� 0 p
Me Labor Code,for the performance of the work for which this permit is Issued.My Worker's 1
,the
etlon Insurance carrier and Policy n ber ere: I �� Total
Cenier Policy No. 3!7 z 273 PERMIT AUTHORIZATION DATE
CERTIFICATEEN COMPENSATION
IOURANC WORKERS'
COMPENSATION INSURANCE N.C{]
(This sectim need not be completed g Me permit Is for ane hundred dolls(5100)or lase.)
certity that Tri the perbrmence of tiro work lar which this permit Is Issued.I shall not amptoy
any person in any manner so as to become subject to the Workers'Compensation laws of Call- All roofs shall be inspected prior to any roofing material being
brnie. 1. installed. If a.roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
� otr APPLICANT: It, of tiemr«mbb�
subject to wre rovious Cde,yo, �fwitrApplicant understa nd will comply with all non point
with such pro elons or this permit shelCbe deemed revoked. Source regulations. -
I coNlfy that I hese read this alaptioatn and state that the above Informatldn R correct agree
to comply with ell city arra county ordinances ane orate laws relating to building con.wcticn,and II r f coverings to a da
lon "C'or better.
hereby authorize representatives of this city to enter upon the abme-mentioned property far In-
spa purposes.
(We)agree to save,irMemnliy am keep harmless the Chy of Cupertino against IlabllMes,
judgments,costs and expenses which may In any way accrue against said City In consequence
of the granting of this permit. \21DINTATNINEFOIF APPLICANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION:. BATTENS: FINAL: -
ll DATE INSP. DATE INSP. DATE.
NOTE: OSHA APPROVED ACCESS TO ROOF. SHALL.BE PROVIDED FOR INSPECTION
OFFICE COPY