R 5909 ' PERMIT _
APPLICATION FOR
CITY OF CUPERTINO NUMBER R 590 9
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (40$)777-322$ PERMITPIKES IF WORK IS NOT STARTED
WITHIN 18080DAYS OF PERMIT ISSUANCE OR
18
0 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
. CSP 4Solf!
L Z n P-9c S aT. RESIDENTIAL COMMERCIAL OTHER
OWNER'S r A HAZARDOUS FIRE AREA -
NAME �eO2Ge_ el— L e.. A&)N �o l( )I pl VES ❑ If
assembly is requirerstand d
tda Class A _
NO -- Indlal I.C.B.O.q
ADDRESS SItF EXISTING ROOF COVERING
PHONE ZS-Z - 0—+o I NUMBER OF EXISTING COVERINGS 1-^
CONTRACTOR'S L,Q �,
x
'^/- - ( TO BE REMOVED + TO BE RETAINED
NAME �2r�1 A-IS$AA1C� 1�7p�i1J() ,,,,�.JJ
ADDRESSTYPE OF ROOF COVERING
CITYBZIP 2292._ L WCOLAI At) SJ 9,E11,5,
ppQ EXISTING
PHONE y 00 — y Ll V — q�' - BUILT-UP ROOFLICENSE
❑
NUMBER 559 -3 6 ASPHALT SHINGLES P AEP
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 full force and r UN y ^ nemrn
affect. Q 3/31 SHINGLES J (uJ /71Vd U
License Claes G3c� LIC.Number 5sq;3�
p ��/� OTHER(SPECIFY) CITY OF L L _
Date ��/9a Contractor AeAL41SS4AkiP A,"/4;6 )
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Lew for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requlree 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 provislons
oI the Contractor's License Law(Chapter g(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 ❑
axemptlon.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e 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,wlll do WOOD SHAKES ❑ 11 I
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles- Lt C5✓r TI LQ—
alone 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 himsstf or through his own employees,provided that ❑ M 6outee2
such Improvements are not Intended or offered for sale.It,however,the building or Improvement r yr //E2/779-0 e—
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER (SPECIFY) �Iy{r SFL4/t 2..
not bulltl or Improve for purpose of sale.),
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct �lr•3
the project(Seo.7044,Business and Professions Code:The Contractors License Law tloes not PROVID C.B.O. PORT NO. 'LL
apply to an owner of property who builds or improves thereon,and who contracts for such projects
With a Mritre<tor(s)licensed pursuant to the Contractors License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. A 8 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:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, /U Building17 T
as provided for by Seaton 3700 of the Labor Code,for the performance of the work for which this -m(1
mit a laeaed, �O l.�/ $7 o Seismic 1 `30
have antl will maintain Worker's Compensation Insurance,as required by Section 3700 of
th or Code,for the performance of the work for which this permit is Issued,My WOrk7a aa^
mpensabon Insurance realer ander Policy number are: Qd @E ( I 1 Total 17�•SO
Carrier S-T/+Te- FUryy PollayNo. �.r�n�yzs�3 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the permit Is focone hundred dollars($100)or less.) rJ e /9ti7��,lX-c !/J v:HCl•"9�
I certify that In the performance of the work for which this permit Is Issued,I Shall not em toy 6
any person In any manner so as to become subject to the Workers'Compensation Laws of Asa- All roofs shall be inspected prior to any roofing material being
fame, 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: II,after making this Certificate of Exemption,you should became A hcant understands and will comply
subject to the Workers'Compensation prevlBlans of the Labor Code,you must IorIDwlth comply PP ply with all non point
with such provisions or this permit shalpbe deemed raveled. source regulations.
I certify that 1 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 building construction,and All roo Erin S e
hereby authorize representatives of this city to enter upon the above-mantloned property for in.
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, 6 /
judgmental coats and expenses which may In any way accrue against said City In consequence
of the granting of this permit. S ATURE OF APPLICANT DAT f
PRE-INSPECTION: PLYWOOD: X IN-PROGRESS: X
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: )( BATTENS: FINAL: �(
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY