R 5208 PERMIT R_ 5 2 8
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 �y ����//
luko zG04 lJeL RESIDENTIAL COMMERCIAL OTHER
OWNER'S ) HAZARDOUS FIRE AREA
VES ❑ If yes
assemby srang thed.aClassA
NAME iC /L/°�/oz/l NO _ Initial I.C.B.O.W
ADDRESS 19' 7 Af,67-aox EXISTING ROOF COVERING
PHONE VVV
�s 4f — /Il NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
kU " ( J TO BE REMOVED TO BE RETAINED
NAME ESS ` '/ �/ /"-�'�J� //
CITYADDRBZP ✓&�� /'��/� CIrIl"ST��L7�I� TYPE OF BOOF COVERING
,4
EXISTING pqt l0*P Fp /
PHONE r l9lofl BUILT-UP ROOF F��btel
LICENSE
NUMBER �/ 7 e3J�d ASPHALT SHINGLES
.LICENSED CONTRACTORS DECLARATION
IQ
hereby Di affirm that em Business
licensed under provisions of Chapter y(commencing with Section WOOD SHAKES ( /
7000)of Division 3 0l the Businem end Profesalone Code,and my license is In lull farce and
effect. 1
G°3 <0�5/3�da WOOD SHINGLES ❑
License Claes Llc.Number
Date --
/0'/S`9fe Contractor Oje- � OTHER (SPECIFY) ❑
q,
OWNER-BUILDER DECLARATION
I hereby affirm that I em exempt from the Contractor's License Law for the following reason. PROPOSED "7
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to p � O
construct,alter,Improve,demolish,or repair any structure,prior to its Issuance,also requires the BUILT-UP RO 1 lam'
applicant for such permit to file a signed statement that he is licensed pursuant to the
provisions applicant
of the Conlractor'e License Lew(Chapter 9(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 SHING -
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to CGS,
a civil penalty of not more than live hundred dollars($500),):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES O❑
the work,and the structure Is not Intended or offered for sale(Sec.7044.Business and Profes
slons Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself ar through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.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,am 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 contmctons)licensed pursuant to the Contrectoes License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason
Owner oats
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration; / w/_ /
❑1 have and will maintain a Certificate of Consent to salt-Insure for Worker's Compensation, /40"/ J�%V
as provided for by Soctlon 3700 of the Labor Code,for the performance of the work for which this / /7 Building
permit Is Issued,Coe, Seismic
nave and will maintain Worker's Compensation Insurance,as required by Section 3700 of
C Labor Cotle,for the performance of the work for which this permit is issued.My Worker's
'
Compensation Insurance carder and Policy number are: Total �!
Carrier wST � 1Cfl/�d Policy No.�agbZ0fO PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C. D
(This section need not be completed if the permit is for one hundred dollars($100)or lase.)
I certify that In the performance of the work for which title rmlt Is Issued,I shall not employ fill
any person In any manner so as to become sub' ct to the rkers'Compensati Laws of Can. All roofs s II be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date , �5"9p Applicant inspection,I agree to remove all new materials for inspection.
NOTICE subject to theOWorkers'Compensation orafter k.I. nye at theficate LabolCode,Exemption,
must forthwith omplyy Applicant under s and will comply with all non point
with such provisions or this permit shell s d emed revoked. source regulate
I certify lbetlhave reed Ibis epplicatlokpistate that the above information Is correct.l agree
to comply with all city and county ordinances and stele laws relating to building construction,and All roof OV gs to be class" or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities, � x-4 „
judgments,costa and expenses which may In any way accrue against said City In consequence
• of the granting of this permit. 1 A URE 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