R 5914 APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5 914
INSPECTION DIVISION PERMIT EXPIRATION
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
lO l 2 RESIDENTIAL-Z COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
(r�
YES ❑ If yes-I understand that a Class A
NAME—_ Lommol OF Q,V irt0oof assembly is required.
NO Initial I.C.B.O.#
ADDRESS t EXISTING ROOF COVERING
PHONE 39S O NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S
NAME Los C/�igme, Roomy.
l-0oomya TO BE REMOVED L TO BE RETAINED
ADDRESS -f' TYPE OF ROOF COVERING
cir lP 1'1l l SMTTH Ra. ., � d0.fb 9S!/Z -
EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE ❑
NUMBER $ (o ASPHALT SHINGLES
LICENSED
underCONTRACTORS DECLARATION -
-thereby affirm that em Business
licensed under Professions
lone of Chapter 9(commencing ullih Section WOOD SHAKES
7000)of Division 3 of the Buelnese entl Profeaslons Cotle,and my license Is in full force and
effect. e WOOD SHINGLES ❑
License Class l:- &1 Lic.Number q'I
Data
Cit, -o4-I8 Contractor LOS 6yits ROon-R, OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Lew for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct.alter.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 that he Is licensed pursuant to the provisions
of the Contractors License Law(Chapter a(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Sectlon 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more man five hundred dollars($500).):
E]1, SHAKES bQ
I,as owner of the property,or my employees with wages as their sole compensation,will do
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
slons Cod°:The Contractors License Law does not apply to an owner of property 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 sale.II,however,the building or Improvement g�y�
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFV� � � ❑
not build or Improve for purpose of sale.).
El 1,as owner of the property,am exclusively contracting with licensed contractors to construct p.�
the project(Sec.7044,Business and Professions Code:The Contractors License Lew does not PROVIDE I .R PORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects p( -s9 �Q�/pq�,
with a am exempt
unlicensedrSe pursuant to the Contractors License Lew. PROVIGOtGR.INS IAL'l2FJTION SPECS.
❑I em exempt untler See ,B 8 P.C.for this reason ,-
ur'
ownerData APPLICATION DATE VX1!19&ION ' PERMIT F
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declaration:
[J I have and will maintain a of the
of Consent to eels-Insure for Worker's Compensation,this BUll�irT
as provided for by Section 3]00 0l the Labor Code,for the performance of the work for which this (\���f
permit Is Issued.and (] y SelSml
❑1 have and will maintain Workers f the work
for which this as required u Section 3700 Of Ob _Ot,l _-1 W loo
the Labor Code,for the performance of the work lar which this permit Ie Isaustl.My Workers
Compensation Insurance carrier and Polity number are: J Total
Carrier AasaurA.t F61POl07.1 Policy No. EBQ 12E045-OQ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.]
(This section need not be completed If the permit Is for one hundred dollar-($100)or less.)
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any person In any manner so as to become subject to the Workers'Comptnaetlon Laws of Cali. All roofs shall be Inspects prior to any roofingTIQ
ental being
f°`"ie. ''� installed. If a roof is installed without first obtaining an
Date Ole -64-99 Applicant � ✓$ � inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: 11,ager making this Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked, Source regulations. -
I certify that I have reed this application and stale that the above Information Is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to be class"Ci"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes. /'a
(We)agree to save,Indemnity and heap harmless me City of Cupertino against liabilities, Old_oq-fi?
judgments,costa and expenses which may in any way accrue against said City In cone-------- SIGNATURE OF APPLICANT DATE
' of the 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
J
OFFICE COPY