R 5747 (2) R- 5747
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER -
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
ti /S lJ M �s re 2 A VL RESIDENTIAL X COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class A
NAME— i "-' ^y roof assembly is required.
,��
NO ❑ Initial I.C.B.O.q
ADDRESS 460 ✓L; EXISTING ROOF COVERING
PHONE d cl 3— a6 1 NUMBER OF EXISTING COVERINGS /
CONTRACTO 'S
NAME ,T
.4 7_14V 0 If �C 2✓, TO BE REMOVED x ` TO BE RETAINED
ADDRESS p �e, absZ-`s4_6�6�d� /14,, ,
7j-u%1
TYPE OF ROOF COVERING
CITY&ZIP EXISTING
PHONE BUILT-UP ROOFLICENSE
❑
NUMBER � ) �'� 3 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm.thet I em licensed under provisions 01 Chapter g(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is in lull force and
effect.
C q l b /J— WOOD SHINGLES El
License Class LIC.Number "
Cw e(Lt(QAL OTHER(SPECIFY) ❑
Dela Conirasor
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am 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,alter,Improve,demolish,or repair any Structure,prior to Its Issuance,also requires the BUILT-UP ROOF �71A
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contrectore License Lew(Chapter 8(commencing with Section]000)of Division 3 0l the ❑/®y"
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 clvil penalty of not more than live hundred dollars 500).): _ t/tICCD SHAKE)
❑1,as owner of the property,or my Still
ti loyseaw hwage enation,will do ❑
the work,and the structure is not Intended or offer o sale IS M4,Busin - 1� �[�'/r
slapns Code:The Contractors License Law tl Ias n y t0 a & f proper y no b f WOOD SHINGLES ❑ !T
improves thereon,and who does such work hlmSol t ough own ptoya s provld I
such improvements are not intended or offeretl for . 1,howevee the builtlIng or Impro 1 ,/ /v yN 2 t•CC
is 8 I within one year of completion,the owner-0u' illfKyntl�o aend(provingths d OTHER(SPECIFY) 116x`I
not build or improve for purpose of sale.). VV ll�i ��pp((]]((�� 'l p
E]1.as owner of the property,am exclusively c acdngwithlicerised c ntr4do7Qoc or �V/ �.
the protect(Sec.7044,Business and Proleeelona tlo:The ConVector'e Liconee Lew of PROVIDE LC.B.O.REPORT NO.
apply to an owner of property who builds or Improveihareon,entl who contracts for such r is
with a contractors)licensed pursuant to the Con m8VS License Law, PROVIDE MFGR.INSTALLATION SPECS.
[JI am exempt under Sec. J 8 P.C.for this rea on
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 the performance of the work for which this 6
per�pl IS is9uetl. l�^Z`7 l e� O
pl have and will maintain Worker's Compensation Insurance,as required by Section 3700 of /� D/I� SaISRIIC �
ih L bar Code,for the performance of the work for which this permit Is Issued.My Worker's 131000
Compensation Inurence carrie//s�''e'ntl Policy umber ere: Total
Carrier STq--T� l� is Policy No.61060o2 -SW_
PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N
(This eeslon need not be completed If the permit Is for one hundred tlollars($100)00)or lase.) dl
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 become subject to the Workers'Compensation Laws of Cali- All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOT CE TO ecome
subject t.the Workers'Compensation proviafter sions of the ll Labor Code,cate of yolu Mustuforthwitlhocomply Applicant understands and will comply with all non point
with such provisions or this permit shalQbe deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information is correct.I agree
h complyyauthorizeh all
rep entl county at(hi sits and entero on the
above-above-mentioned
property
fand All r00(,pOVeringS b SS�Or better.
hereby authorize city and county
of ordinances
city to enter upon Ire Bing to building
construction,proprly for In-
spection
n- All
rocift
sp(Wre) purposes.
(Wen agree tos Nye,indemnify and keep harmless the City of Cupertino y Inagainstn liabilities,
ence
of the nar,costa and expenses which may In any way accrue against aeltl City Inconsequence SIGNATURE OF APPLICANT
of the granting of this permit. 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