R 5894 PERMIT R_ 5894
.
APPLICATION FOR CITY OF'CUPERTINO NUMBER
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 -/
L i 3 �a� p 11 1 ✓ " ' - RESIDENTIAL v COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
e\ 1, YES ❑ It yes—1 understand that a Class A
NAME �--5 roof assembly is required.
• I NO ❑ Imaal LC,B.O.b
ADDRESS S �` � A S Ot S, �/ ' EXISTING ROOF COVERING
•�- PHONE I r Z4' g 7 NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S r� ,ry(J, p
NAME N O Q� �1 ~(I � C�`r 11 •���p�.) N �f TO BE REMOVED! hh TO BE RETAINED
ADDRESS ' S-p S7 W I N CY��P tQ^ ' TYPE OF F 713;_X., e CITY&ZIP—3 S 1J I.UI !0S"
EXISTING
PHONE- /
y s � 3CylR •
BUILT-UP ROOF ❑NUMBERLICENSE 7Q'' 9 `� ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section -WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect.
tax 2 WOOD SHINGLES
License Class s T �'y^ Lic.Number J ❑
a Q' OTHER SPECIFY
Date 2 6 Contractor �+�'�"� �<1'�tif✓ (SPECIFY) ❑
OWNER-BUILDER DE RATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law 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 Contractor's License Law(Chapter B(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
exemoften.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).):
L]1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES
ecr0
the work,and the structure Is not Intended or offered for sale(S .7044,Business and Profes-
JUN V,
sions Code:The Contractors License Law does net apply to an owner of property who builds or WOOD SHINGLES t ❑
improves thereon,and who does such work himself or through his own employees,provided that �r
such Improvements are not intended or offered for sale.If,however.the building or Improvement _l 1 Ut I✓ur�r\)f
Is sold within one year of completion,the owner-budder will have the burden of proving that he did OTHER(SPECIFY) Q---- ��
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044.Business and Profession°Code:The Contractor's License taw 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 Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
O
I hereby affirm under penalty of perjury one of the following declaration: 1JJ Q D O ,`�
❑I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, 6 2 �/ 3 Building�_
pe mit Is is for by Section 3700 of the Labor Coda,for the performance of the work for which this
permit is issued,and. Seismic
❑ have and will themaintainrt Workers Compensation Insurance,as required by Section 3700 0l
the Labor Code,for the performance of the work for which this perms Is issued.My Workers
Compensation Insurance carrler a Policy number are: Total
Carrier 5 ��LUNA Policy No.!ya�9O ! PERMITAUTHO N DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' ,
COMPENSATION INSURANCE N.C.[]
(TMs section need not be completed If the permit Is for one hundred dollars($100)00)or IeeeJ IAV_
I certlfy that In the performance of the work for which this permit is issued, shall not employ
any person In any manner ear as to become subject to the Workers'Compenselion Laws of Call. All roots shall be inspected prior to any roofi mater) I i
°f"I"' 14
installed. If a roof 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 Certificate of Exemption,you should become Applicant understands and will comply with all non oral
subject to the Workers'Compensatlon provisions of the Labor Code,you must forthwith comply pP p y p
with such provisions or this permit shall 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 wlth all city and county ordinances and stale laws relating to building construction,and All roof coverings to be class°C"Or better.
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 City of Cupertino against Ilsbilities,
jutlgmente,coals and expenses which may In any way accrue against said City in consequence
of Ne granting of This permit. SI NATURE OF APPLICANT DATE
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