R 5469 APPLICATION FOR CITY OF CUPERTINO
NUMBER R-' 5 4 6 9
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR'
BUILDING ADDRESS
180 DAYS FROM LAST CALLED INSPECTION.
' ,{�xy /-�_ ,1II
Z252� G �� ' RESIDENTIAL_ COMMERCIAL OTHER
OWNER'S ,,,�/ HAZARDOUS FIRE AREA
j l( M YES .b If yes-I understand that a Class A
NAM ll� i li, W-��� / roof assembly is required.
NO ❑ Initial I.C.B.O.#
ADDRCQQ J Me,&JCGGlJo`
EXISTING ROQEC:OVERING
PHONE 4081 Z53- 4,Q� NUMBER OF EXISTING COVERING
CONTRACTO�R'S/
NAMF
I v WVa. �Qa!� TO BE REMOVED_, TO BE RETAINED
ADDRESS i .^ TYPE OF ROOF COVERIN
CITY&zip e-ro��� L4 , • EXISTING
PHONE(`7`2%) Z2 -UP ROOF El
LICENSE
NUMBER (00q459C) ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES P A
7000)of Division 3 of the Business and Professions Code,and my license is In lull force and
effect G b WOOD SHINGLERoff n❑
License Class Lic.Number_K/`! • — • 6
OTHER(SPE®I ) (�
Date I 1 Coined
-BUILDS G _ OF uur
OWNER-theConRDECL License PROPOSED EhtifNU
hereby affirm that am exempt from the e: Any ore License Law for the far Ing r aeon.
construct,7031.5,r,Imp ove and Professions Code: Any clry or county which recut rmll to
construct,alter,Improve,to file signed or repeat any structure,prior to Its Issuance,also requires the BUILT-UP ROOF
applicant for such permit a Ills a signed r 9(commencing that g ithcena o 7000)pursuant m the provisions •�
of the Contractors License Lew(Chapter 9(commencing with Section 7000)of Division 3 of the ��.,/ �{.� t I
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES 'bSL l 'G'St� G
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dollars($500).): 11
❑l,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑ �'� ��
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles-
Ilona Cope:The Contractors License Law does not apply to an owner of properly who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sate.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Lew does not PROVIDE I.C.B.O.REPORT NO
apply to an owner of property who builds 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.
E]I am exempt under Sec. ,B 8 P.C.for this reason
Owner ate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PE MI;FE
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, BUlldln b
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 2/�
permit IS Issued. / (/ -7 ( /�-+�✓. Selsm C
❑I have and will the peon Workers Compensation which this as required Is u d,My 3700 ke's
the Leber Cotle,for the pertormenee of the ork for which this permit is lesuetl.My Worker's
Compensal n net nce Corti nd Policy most ere: Total
Carrier. iJ PolicyNo.2-86-Of7 PERMIT AUTHORIZATION � _ DATE
CERTIFICATE OF EXEMPTION FROM WORKERf�U/Q ,.' -
COMPENSATION INSURANCE N,C.D .I I �
(This section need not be completed if the permit Is for one hundred dollars($100)or less.) ` I
I certify that In the performance of the work for which this permit to Issued,I shall not employ
any person In any manner so as to become subject to the Workers'Cam enaat Laws of Cali. All roofs shall be rnspencted prior to any roofing material being
fornia. /' installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE N APPLICANT: If,after making this Certificate of Exemption, u sh Id become A Iicant understands and will com I with all non Dint
subject to the Workers'Compensation provisions of the Labor Code,you on rt Ith comply PP P y P
with such provisions or Ihl6 permit shelf;be Deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information Is correct.I agree
to comply with all city and county ordinances and state laws relating to bulldmg construction,and All roof covert to babeOc1�l/B[/�)�S"CCi"or better. q
hereby authorize representatives of this city to enter upon the ebovo-mentlonetl property for In- �`! "'—_ 7 / / 1�
hereby purposes,
r
(We)agree to save.Indemnify and keep harmless the City of Cupertino against liabilities, t VI
judgments,costs and expenses which may In any way accrue against said City in consequence
of the granting of this permit. SIGNATURE OF APPLICAW—I DATE
• PRE-INSPECTION: PLYWOOD: IN•PROGRESt,J
INSP, DATF INSP. DATE INSP. DATG
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP DATE _ - INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY