R 5961 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R_ 5961,
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT ryr /� I4DA) ]]-3ZZ6 PERMIT EXPIRES IF WORK IS NOT STARTED
!/XJ�/F/• tel` WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS y/-'
1,!9d 2 Le a _V
RESIDENTIAL COMMERCIAL ' OTHER
OWNER'S JrHAZARDOUS FIRE AREA
n ES ❑ If yes-I understand that a Class A
NAME
QTY!M O�'! S O'Y' �- roof assembly is required.
LNO 13 . nitial LC.B.O.#
ADDRESS S03 EXISTING ROOF COVERING
PHONE O8' , J ' �(p!/ NUMBER OF EXISTING COVERINGS
CONTRACTOR'S G �S
TO BE REMOVED TO BE RETAINED
NAME C
ADDRESS17jr /h o/ l GS � TYPE OF ROOF COVERING
A CITY 8 ZIP r Y_ 2G z _��� EXISTING
PHONE !�Ide 3S S- 1Z3-3 BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with SectionWOOD SHAKES IAC
7000)of Division 3 of the Business and Professions Code,and my license is In full force and 7
effect.
9 (/� ❑
License Class� Lic.Number ` _57
OD SHINGLES _
Date Contractor
O ECIFY) ❑
OWNER-BUILDER DECLARATION pROP�SE
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 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
e civil penalty of not more than five hundred dollars($500).):
01,as owner of the property,or my employee a with wages as their sole compensation,will do WOOD SHAKES
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 will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose Of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(See.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NQ;
apply to an Owner of property who builds or improves thereon,and who contracts for such projects
with e contractor(s)mexemptunlicensedrSe pursuant to the Contractor's License few. PROVIDE MFGR.INSTALVTION SPECS. �Q
❑I em exempt under Sec. ,B 8 P.C.for this reason y�/L
PA
Owner - Date APPLICATION DATE • A4U TION ERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: ' Lx I
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, VrLry ro vildln
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this //�� Y g 100/�9 �
permit Is Issued. ,q5 (Fern Seismic
❑ have and will maintain Workers Compensation Insurance,as required by Section 3700's 'VV /
,the Labor Code,for the performance of the work for which this permit Is issued.My Worker's ,�
Compen/ewe/(t//�/yln�sl�u]ra�nce/c�errher en I�lcy7/�/ym r re: Total r
Carrier�a" I;=:Policy Policy Na�1.���Uo yqS� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CD
(This section need not be completed If the permit Is for one hundred dollars($100)Or less.) ,� r CD 967
1 certify that In the performance of the work for which this permit Is Issued.I shell not employ f �J
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.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become
subject to the Workers'Com ensatlon provisions of the Labor Code, Applicant understands and will comply with all non point
with such provisions or this permit shelbe doomed revoked, you must lorlhwith comply source regulations. p Y
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 stele taws relating to building construction,and All root COVef gs 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 ands,Indemnify and keep harmless the City ai Cupertino against ilebllitiee, L7J7�� Z 9G
of the gran,costa and expenses which they In any way accrue against said City In consequence
-� of the granting of Imo permit. SIG A RE OF l�fiLIC T DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:'
INSP-- DATE INSP. DATEINSP. 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 -