R-5569 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5 5 6 9
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
180 DAYS FROM LAST CALLED INSPECTION,
7-14730 0AV- n 0 LL. `T
- RESIDENTIi COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
C�A2 Lm E f�*
Ct ... J E L`.4 YES ❑ 11 yes
=a I untlerstand that a Class A
NAME W roof ssembly Is required.
NO Initial I.C.B.O.#
ADDRESS Z1�3U OAlcnoc.G CZ'. EXISTING ROOF COVERING
PHONE ZS 3^ L{ ZS NUMBER OF EXISTING COVERINGS
CONTRACTOR'S t
Il�l.4lYls T7_a� TO BE REMOVED TO BE RETAINED
� NAME ll��
ADDRESS TYPE OF ROOF COVERING
CITY a ZIP (03f q LA-5 oxviAS. u �rr`'- EXISTING
PHONE Z��' - SI 2 c BUILT-UP ROOF ❑LICENSE
'
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
qWOOD SHINGLES ❑
License Class C'�3 ` Lift.Number L17 yo 99
Date g Z/y—�Contractor 5 OTHER(SPECIFY) ❑
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
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions -
of the Contractor's License Lew(Chapter a(commencing with Section 7000)of Division 3 of the
Business and Professlors 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 SHAKES El
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 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-nullder will have the burden of proving that he did OTHER(SPECIFY) ❑ r� ya' �Lk'
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law tloes 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 contractor(s)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason
Owner Date AP ICATIO D E VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
( I hereby allirm under penalty of perjury one of the following declaration: ,`_ A
❑1 have and willmaintain a Certificate of Consent to self-Insure for Worker's Compensation, "�(j Building
00
as provided for by Section 37of the Labor Code,for the performance of the work for which this
ftz
permh la Iveued. l�Ur
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of L"(/P4r1yr VO Or 000 Seismic
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's / Total
Compensation Insurance carrier and Policy number are: �r
Carrier SLATE �d Policy No. l rI,873by 'T 7 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If 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 shall not employ
any parson in any manner so as to become subject to the Workers'Compensation Laws of Cell. All ri spall be inspected prior to any roofing material being
ferrle. G1 /J installed. If a roof is installed without first obtaining an
Date / Z!APPLICANT:
Applicant �f"� inspection,I agree to remove all new materials for inspection.
NOTICE TO If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P Y P
with such provisions or this permit shalCbe doomed 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 laws relating to building construction,and All roof cov rings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
apache)purposes.
(We)agree to save,Indemnity and keep harmless the Clry of Cupertino against liabilities,
' judgments,costs and expenses which may In any way accrue against said City in consequence SIGNATURE OF APPLICANT DATE
of the granting of this permit.
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