R 5916 (2) i I.ah
PERMIT R_ 59
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
• WITHIN DAYS PERMIT ISSUANCE OR J q C DANS FROM LAST
CALLED INSPECTION.
BUILDING ADDRESS
D rest RESIDENTIALL COMMERCIAL OTHER
OWNER/'S�� /� ///� HAZARDOUS FIRE AREA
NAMEI:omm nn c Q IP ( �Ij A20 Q � 9 YES ❑ If yes—I understand that a Class A
��n roof assembly is required.
/ NO ❑ Initial LC.B.O.#
ADDRESS 72—-7 GL//a t Ve rs/TV L(T EXISTING ROOF COVERING
ONE
/
— f0 G G 9cS° 31 NUMBER OF EXISTING COVERINGS 'I
PH
CONTRA OR '
TO BE REMOVED__J_TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING .
CITYBZIP
,/ 953 Ex�TNI�
PHONE ZOO' 3SB-1L/3� BUILT-UP ROOFLICENSE
❑
NUMBER 7W ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 0(commencing with Section WOOD SHAKES /'➢—'q'�_
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
eat.
Li 7�j/ / WOOD SHINGLES ❑
License Claes x.39 Lic.Number �9
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
1 hereby affirm that I am exempt from the Contractors 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 11applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Law(Chapter a(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
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).): WOOD SHAKESE]I,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 Contractor's License Lew does not apply to an owner of property who builds or IWOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided tggaaJJ
such Improvements are not Intended or offered for sale.if,however,the building or ImprovernI
Is sold within one year of completion,the owner-builder will have the burden of proving that he did �ER(SPECIFY) El
build or Improve for purpose of sale.). O �{J
❑I,as owner of the property,am exclusively contracting with licensed contractors to cons
��q
the project(Sec.7044,Business and Professions Code:The Contractors License Lew doep PR9,VIDE I.C.B.0.REPORT NO.
with ato an owner of cont actorr(s)licensed pursuawho nt 10 the s or Improves
ontractorr's License Law, I;.
for such Prot to JT I;. q
❑I am exempt under Sec. B6 P.C.for this r B Vr PROVIDE MFGR.INSTALLATION SPECS. LG
OwnerData
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: �s
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, - Building �� `•s.
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this / ^
permit Is Issued. —1 �•,
99
❑1 have and will mainland Worker's Compensation Insurance,as required by Section 3700 of Seismic Ir. ",
the Labor Code,for the performance of the work for which this permit is Issued.My Workers 9 /� Total 8 n�
Compenee�thonInsuance artier yW nu�bar ere: / �}
Camr�m�///�An /,iXecy ion Policy lyyri,�[}�� 7,50 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.[]
(This section need not be completed of the permit Is for one hundred dollars($100)or less.)
1 certify that in the performance of the work for which this permit is Issued,I$hall not employ
any person In any manner$o as to become subject he Wolkere Compensation Laws of can- All roofs shall be inspected prior to any roofing material being
fornia, installed. If a roof is installed without first obtaining an
Date C-/�-t8� Applicant �•' inspection,I agree to remove all new materials for inspection.
. ecome
subecttI.theOWorkers*Compensationprovisions oftheflLabor Code,you mustufothwllshouithbcomply 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.)agree
to comply with ail city and county ordinance.and state laws relating to building construction,and All roof eings to be class Aor better.
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 againstIlabnlitlas,
judgments,coats and expenses which may In any way accrue against said Clty In consequence
• of the granting o1 this permit. SI TURE OF hP1SLICANTT 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