R-5828 APPLICATION FOR CITY OF CUPERTINO
NUMB RR-PERMIT
5828
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT - (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN IW DAYS OF PERMIT ISSUANCE OR
p 180 DAYS FROM LAST CALLED INSPECTION.
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%ll (oD� L�/LK1KJ50✓✓ ff✓
RESIDENTIAL - COMMERCIAL - OTHER
OWNER' rA` y HAZARDOUS FIRE AREA .
'V/�- YES ❑ tlyes—Iubly is;
ire .hat Class
NAME roof rusembry q requimtl.
NO initial I.C.B.O.7
ADDRESS LL✓✓']] (/ (,//�,// EXISTING ROOF COVERING
PHONE �.71/� — ! �a / NUMBER OF EXISTING COVERINGS
CONTRACTOR'S _ _ ryrnl /y/
(�L,Q ((( TO BE REMOVED _✓ TO BE RETAINED a"
NAME
ADDRESS /S3-37 LWI,fAA/ GasI/S TYPE OF ROOF COVERING
EXISTING
PHONE 69 Q Z� BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION J
I hereby affirm that I em Ibensed under provisions of Chapter S(commencing with Section WOOD SHAKES `aCY11
7000)of Division 3 of the Business and Professions Code,and my Ill I I force and
effect. /
WOOD SHINGLES
1-ce a Cked— _ Lie.Number
S�33 ,❑ _
/p
Date rector OTHER(SPECIFY) /
Cont `
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that am exempt from the e: Any ore orLicensecoup Lew for the browing meson. ��
(Sec.] t, It Beninese and Professions rep Code:structure,
cry or county which requires a permit h
corsbuct,or suhpmva,damns a sindstaementrMate,priortope Issuance,pursuant also reguireethe BUILT-UP ROOF
of to
for such Paten to L a a elgnatl armament that he i licensed pursuant to the n 3 of the
m rhe C no[Pre License Law(Chaplet B is ex a exempt
with section the b of for the 3 of the
4 Badness ens Profasdloo f Sopron
or 1.he is exempt antfor a and the bents for the mans to ASPHALT SHINGLES ❑
exsmptlon.Anyf not on of Sec Non hundred
by any eppl ).for a permit subjects the applicant to
e civil penury of not more than floe y arnpl dean (Swage
❑Lea owner mheture in of I tended greeewlhwegeeeeihmrac,compess and Pr111tlo WOOD SHAKES ❑
Me work,and he mnemes b not Intended or offered for ems(Sec.7044,Business end Profen- -
mono Code:The Convectors License Lew does s trot apply to an owner of property who builds eOr
t WOOD SHINGLES
Improves thereon,end who does deco work himself or Nrouoh his awn empbng or Improvement provided tent
such Improvements one are not Intended m offered for ems. ill however,the fincen of pr or g that he did
nsectlwHfrno0eyear for foumple of sthe owner-Wilder will have the burden of gra+ingthathetlb OTHER (SPECIFY)
not build or Improve for purpose of sale.). i
❑1,as owner of lire property,am exclusively contracting with licensed contractors to contras
the protect(Sec.7044,Business end Professions Code:The Conlrac or's Ucen ie Lew dose not PROVIDE I.C.B.O.REPORT NO. S/e�
apply to an owner of property who bunks;or Imprensa thereon,and who contracts for such projects
with a contrectods)licensed pursuant to vire Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason
Owner Date APPL A 1DATE VALUATION PERMIT FE
WORKER'S COMPENSATION DECLAMTION
I hereby affirm under penmry of perjury one of fine following decameter:
❑1 have and will maintain a CertlNcme of Consent to self4nnure for Worker's Comperhemion, J®M O 1 ..,�` BUII n
as provided for by Seoul 3700 of Ne Labor Cade,for he performance of the work for which this n FI �rUl '
permit le Issued. Sets IC
11 have and will mabtmn Workers Compensetlon Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this pal is asued.My Workers fY LIJr-Cn I IIVI-, Total
Cemperhmibnl�rrler erM pdky�ber en: /Q�/ l
Carder rG�—•
Policy No. 13 Yr 3_4 o PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE si C
(This section need not be completed it the permit Is for one hundred dollars($1 a)or lase.)
I certify that in the perlormence of the work for winch this permit is Issued.I shall not employ
any Penson in any mannor se,as to become subject to the Workers'Compensation Laws of Gal All roofs shall be inspected prior to any roofing material being
fondle. installed. If a roof is Installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
oloEoke� aatpxeohicyou �uo
subethwrs'Comperbn roWkhf Conti
boCoa, omforinyttry 'Applicant understands and will comply with all non point
wish each provlslo s or this permit shall be deal ral source regulations. -
I candy hal I have read this application and elate that she above Informal Is canes.I agree
to comply,with all cry and county ordinances and elate laws relating to building construction,end - All roof rin 0 B C"or better.
hereby authorise representatives of ole ply to enter upon the above-mentioned property for In- I _�� f
hereby
purposes. C/ �,'/a/
(We)agree to says, Indemnify and keep harmless the Cly of Cupol and net Ibblliff",
j, we)
costs and expenses which may In any way accrue against sold Clry In conaequenro ATURE OF APPLICANT DATE
of a 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
.OFFICE COPY