R 5178 PERMIT R_ 517 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
BUILDING ADDRESS
Z
180 DAYS FROM LAST CALLED INSPECTION.
(� / A/�
Z L/ J8 14 ve RESIDENTIAL COMMERCIAL OTHER
OWNERS
�y,�,.,^1 uA 0/^ HAZARDOUS FIRE AREA
4- Alt$. &7 N/4A YES {(� IF yes-l understand thatClass A
NAME ill
roof assembly is required.,
/,, /� NO . LlInitial I.C.B.O.M
ADDRESS-2'Z e4 P S4NT`+ P4U1A ryyC. EXISTING ROOFCOVERING
PHONE 2 S't 7 D NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME C'v2vIeRS�a1v,P /}pQ!�/e7TO BE REMOVEDTO BE RETAINEDn01'/C�
ADDRESS TYPE OF ROOF COVERING
CII SCL79�1 WR11•Rrp L4ne, 54rf3'vSe(i4 f
Vi EXISTING
PHONE '161-7l01�3 BUILT-UP ROOF
LICENSE
NUMBER (/J CI '2014b ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby affirm that I em Business
licensed and
Pr provisoes of Chapter 0(commencing wllf Section WOOD SHAKES
7000)of Division 3 of the Buelness antl Pmlesslons Code,and my license Is In lull Mroe and
effect. /�— 17 2 // WOOD SHINGLES ❑
License Claes `- Lic.Number �,vs+
Date 9 0 Contractor CoRNtRJ404e— /lp
dopen5 OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's License Law for the following reason.
(Sec.7031,5,Business and Professions Code: Any city or county which requires a permit to -
construct,altar,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF El
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 theSrp 7 p
• Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ty d 1/199
exemption.Any violation of Section 7031,5 by any applicant for a permit subjects the applicant to JJU
a civil penalty of not more than live hundred dollars($500).): ' I I i ,
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
sions 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 or through his own employees,provldgd,that—-_` ❑
such Improvements are not Intended or offered for sale.If,however,the bulldIng or 1pparvement
IssoId within one year of completion,the owner-builder will have the burden of pr ngmathemd- ..OTHER (SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with llcensetic tr�oloret construct
onetruct l
the project(Sao,7044,Business and Profeselone Code:The Contractor We6nse Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,end who Ire eta for such projects
with a contractors)licensed pursuant to the Contractor's License La
❑l am exempt under Sec. ,B a P.C.for this reason PROVIDE MFGR. INSTALLATION SPECS.
Owner BIB APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLA TION
hereby affirm under penalty of parlury one of the following d darati p p J i ��
❑I have and will maintain a Certificate al Consent to eelbina ra for orkerb Compensation, 9— 1 (tQ Buildin v
as provided for by Section 3700 of the Labor Code,for lho pertor once Il he work for which this
permit Is Issued. `
g ntave and will maintain Worker's Compensation Imeurence, areq fired by Section 37000/ ���('L� SeiamiD rYJ
the tabor Cade,for the performance of the work for which rola rml le Issued.My WorkeYs
Compensation losu/mnce carrier and Polity number ere: Total
Carrier V��*G Fu nQ) Policy No. D 3�'�`r PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS',
COMPENSATION INSURANCE N.C. I
(This section need not be completed If the permit Is for one hundred dollars($100)ar less.)
I certify that In the performance of the work for which this permit Is issued, shell not employ �- YYYY ��' V
any person In any manner so as to become subject to the Workers'Compensatmn Lews of Cell- -All roofs shall be inspected prior to al roofing material being
forms. installed. if a roof is installed without first obtaining an
Date 9 -)8-9� Applicant &4`41441462/3� inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become A Iloani understands and will cora
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP ply 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.I agree
to comply with all city and county ordinances and state taws 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.
ep(We)aurposea. /�-S 9 `1 41
of (We)agree s save,penes w and keep harmless the Clry of Cupertino against liabilities, 3
ofthe gran coats and expenses which may In any way accrue epelnat said City In consequence
of the granting of this permit. SIGNATURE 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