R 5931 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5931
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1Bit DAYS OF PERMIT ISSUANCE OR
1B0 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
1011i C066il PL . RESIDENTIAL COMMERCIAL OTHER
OWNER'S _ - HAZARDOUS FIRE AREA
NAME COMMONS OF CUPERT7n10 YES ❑ Ifoyes�understand iced.hat ClassA
ay q required.
n NO Initial LC.B.O.#
ADDRESS—10145 ' C.Bt.IbRE85 PL. EXISTING ROOF COVERING
PHONE 5 NU BER OF EXISTING COVERINGS I
CONTRACTOR'S •�
OOFTNI(s TO BE REMOVED TO BE RETAINED
NAME LOS "TOS R
ADDRESS C_ TYPE OF ROOF COVERING
CITY aziP 1'1-11 SNtSfH RVE. I .)FlN SASE 95112 XIST ING
'
PHONE (409) 35ik I12A BUILT-UP ROOF ❑
LICENSE
NUMBER - SN II ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
,1 hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect
License
s ❑
lcenee Clees C39 INumber y9534b WOOD SHINGLES
Dl0 Oy 'q$ LoS C�ATes Room& OTHER(SPECIFY) ❑
Date Contrector p
OWNER-BUILDER DECLARATION PROPOSED Psq
1 hereby affirm that I em exempt from the Contractor's License Law for the lollowing reason. -
(Sec.7031.5,Business and Professions Code; Any city or county which requires a permit to
construct,alter.Improve,demolleh,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF J(/
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractors License Law(Chapter g(commencM with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the basis for the allegedASPHALT SHINGLES y/fy(�h 0❑ ss�
exemption.Any violatlon 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).): Uf'
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES �h/hyv
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,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 wl 11 have the burden of proving that he did OTHER(SPECIFY ❑
not build or improve for purpose of Bele.).
❑I,as owner of the property,am exclusively contmctin0 with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors 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 a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
01 am exempt under Sec. ,B 8 P.C.for this reason
Owner Dale
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT F
I hereby affirm under penalty of Perjury one of the following declaration:
01 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Bu In U
as provided for by Section 3700 of the Labor Code,Mr the performance of the work for which this
permit Is Issued, OD $els
❑1 have and will maintain Workers Compensation Ineurance,as required by Section 3700 of rf
the Labor Code,for the performance of the work for which this permit is Issued.M Worker's I
Compensation Insurance carrier and Policy number are: p y DID Ol -�� r Total
carrier AMEUCAN •PROTEGTSOrJ PoncyNo. S� D�n�S-4D PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed it the permit Is for one hundred dollars($100)or lees.)
I certify that in the performance of the work for which this permit Is Issued:I shall not employ
any person In any manner so as to biome subject to the Workers'Compensation Law.of Cell. All roofsthan be inspected prior to anrootirTg Wateriatl5eing
fornla. installed. If a roof is installed without first obtaining an
Data Oto-Dy 98 Applicant ��� inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become
subject to the Workers'Compensation pprovlsions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with Such provisions or this permit shel the deemed revoked. Source regulations.
I certify that I have read this application and slate that the above Information Is correct.I agree
to comply with all city and county ordinances and stats laws relating to building construction,and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to anter upon the above-mentioned property for in.
spection purposes. �/�1
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, UA�Anq L �� QG D/�_9�
judgments,costs and expenses which may In any way accrue against said City In consequence
ohne 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY