R 5927 PERMIT R_ 5927
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
,y�/ � (40777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS
/OD�2 sere a RESIDENTIAL COMMERCIAL OTHER
OwNER's HAZARDOUS FIRE AREA
�j YES ❑ If yes—I understand that a Class A
NAME (N����S G/ (/K.II��' /�61 roof assembly is required.
/ NO ❑ Initial I.C.B.O.N
ADDRESS 0?2n `alh/ ,/!'f`'r IS03O . EXISTING ROOF COVERING .
PHONE Q S— GO NUMBER OF EXISTING COVERINGS
CONTRACTOR'S - /J
/�� 4 .l1 TO BE REMOVED TO BE RETAINED
' NAME Gw CT d.I- DD7�/�J/
ADDRESS
v s z P 0 led,le /pZ� �qs� TYPE OF ROOF COVERING
�/ EXISTING
PHONE- ` Da /V3 &OTHEDRL(SP
F ❑
LICENSE
NUMBER /� NGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 em licensed under provisions of Chapter B(commencing with SectionS
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect' 3 LES ❑
License Cteas L f/ Lic.Number
Date Contractor IFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractoes 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 BUCK permit to Ilia a signed statement that he Is licensed pureuenl to the provisions �®
of the Contractor's License Law(Chapter g(commencing with Section 7000)of Division 3 of the
• Business and Professions Code)or hat he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES `
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500)4: as
❑I,as owner of the property,or my employees with wages as their Bole compensation,will do WOOD SHAKES
he work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profen- vH 111 p+
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 himself or through his awn employees,provided that
such Improvements are not intended or offered for sale.If,however,he building or Improvement V UC
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) C`� ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclualvely 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 amexempt
pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS. _
❑I am exemptmptunder Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
'
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to self-insure for worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for he performance of the work for which this
permit Is Issued Q �I`ham / 60
❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 of .Z-`� 1 x� {��j /y) Seismic
the Labor Code,Ior the performance of the work for which this permit Is Issued.My Worker's /�(/�� ���p e0
CompensaM Insurance carrier and Play n r �Q� '/q� / Total /yB,
Carrier /fes / /=oncyNo.51L/s�slarlJ0PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
100)
(This section need not be completed Ii the permit Is for one hundred dollars($ or lose.) V O C ^` '` (•
I certify that In the performance of the work for which this permit is Issued,1 shell not emjo
any person In any manner so as to become subject to the Workers'Compensation Laws of yaky All roofs shall be inspected prior to any roofing material being
fernla' installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
subject
NOTICE
to the Workers'Compensation n provisionis ofcate of Exemption,ushouldou become
Labor Code,you must forthwith
ect comply Applicant understands and will comply with all non point
with such provisions or this permit shall),,be deemed revoked. 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 bulking construction,and All roof co nngs to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
epedion purposes. —
(W � rhr�! � Z + p�
We)agree to save,Indemnify and keep harmless the City of Cupertino against Ilabllltles, Q' /
ofdthe granting of his permmenn,costs and it,
which may In any way accrue against said Clry In consequence 5 URE OF APPL[CAKT 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