R-5466 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5466
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
31,Xp l �vYC�f�vt���i vl Q . X572
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
F�-4•-� 2l YES ❑ If yes-I understand that a Class A
NAME �� roof assembly Is required.
NO ❑ Initial I.C.B.O.11
ADDRESS -Ilzca 1 G-�ce��,yyr der-ta- I•�e— EXISTING ROOF COVERING
PHONE �0 130 135co 1 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S SOV h
(f(LT II1I , TO BE REMOVED 1 TO BE RETAINED v
NAME ��� "
ADDRESS
OI
I t f � �w _t TYPE OF ROOF COVERING
CITY&ZIP _1`f" til C�
a EXISTING
PHONE 40�— I 2- 14(4S, BUILT-UPR ElLICENSE
NUMBER ASPHALT SHINGII ES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is in full force and
effect.
WOOD SHINGLES 9 ❑
License Class C�� Lic.Number 51 v� I
Date 10 } contractor OTHER(SPECIFY) �❑
OWNER-BUILDER DECLARATION PROPOSED p Px O
I hereby affirm that I am exempt from the Contractor's License Law for 1hoil wing reason.
(Sec.7031.5,Business and Professions Code: Any city or county which req s e permit to �(t
construct,alter,improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF •❑ 5 U
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions v
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
•
Business
antl Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES N ❑ '(11\hJ
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to / LL VUYG
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKESLJC
E]1,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-
sions Code:The Cent"
actor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,andwho does such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.If,however,the building or improvement OTHER(SPECIFY) ® l
is sold within one year of completion,the owner-builder will have the burden of proving that he did f(�jL�eYl a
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 Professions Code:The Contractor's License Law 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.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: 1�7,
1 have and will maintain a Certificate of Consent to self-insure for Workers Compensation, ��� 1 l"'I 6 L4 Bullding d
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this I I v
permit Issued. /
I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of $eISR11C
the Labor Code,for the performance of the work for which this permit is Issued.My Worker's
Comppeenn}}sss((a���kin IInnsurahn-c;e carrier and Policy numb Total
Total
C.mer ' �{"^"''11G eVY1111 TYPafiey No.17831401 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTIO FROM WORKERS'
COMPENSATION INSURANCE 100)o + ^ ^� t
(This section need not be completed if the permit Is for one hundred dollars($100)or leas.) o l/ _—1 lY
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'Compensation Laws of Call. All roofs shall be inspected prior to any roofing material being
fornix, installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
subject io maWorkers'Compefnsati n proivisionls ofthelcate of Laborr Code,you mustforthwith bcomply 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 read this application and state that the above information is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction,and of coverings to a ass" Bitter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection
n- ♦ ,,�•
sp we) purposes. A 1 O / w/
(We)agree to nave,indemnify and keep harmless the City of Cupertino against liabilities, 'V 1� I f—/
judgments,costs and expenses which may in any way accrue against sad City In consequence SIGNATURE OF APP AN DATE
• of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IWPRO SS
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: Q BATTENS: FINAL:
INSP.—DATE ���� 1�9 INSP. DATE Ni DATE
NOTE: OSHA APPROVED ACCESSTO ROOF'SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY