R-5593 1PERMIT
ERR— .5593
APPLICATION FOR clTv OF cuPErarlNo NUMB
INSPECTION DIVISION PERMITEXPIRATICHN
REROOF PERMIT (408) M-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR.
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
.RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
Q - y/� YES I] If yes–I understand tllat a Class A
NAME4'y,,� 'y,, +Q/t'" roof assera6y is regiured.
NO Initial I.C.B.O.it
ADDRESS �— EXISTING ROOF COVERING
PHONE C? ? i 2-01 NUMBER OF EXISTING COVERINGS I
CONTRACTO
NAME
TO BE REMOVED TO BE RETAINED
^
ADDRESS _ TYPE OF ROOF COVERING
CITY a ZIP
q5 a O G
PHON BUILT-UP ROOF ❑
LICENSE // G
NUMBER lD p L ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION -
1 hereby affirm that I an,licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
7000)of DMSIon 3 of the Buslnees end Profession.Code,and my license Is In lull force and
effect 9 WOOD SHINGLES
License Class �' • Uc.Number /! El 4 contra'« OTHER(SPECIFY) El
OWNER.BUII DI RAIbN PROPOSED Y
1 hereby affirm that I em exempt from Me Contractor's License Lew for the ItHoMitg me..
(Sac.7031.5,Business and Professions Cade: Any dry or county which requires a permit to D A '
croshurcl.alter,Improve,damdlsh,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF s�
applicant for such permit to No a stoned statement Mat he la licensed pursuant to this provisions
of Me ConVeclore Ucenas Lew(Chapter 9(cammenclna with Section 7000)of Division 3 of the ft
Business and Proleasicns Code)or Mat he is exempt therefrom A anti the basis far the alleged ASPHALT 13S Arp -
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects Me applicant to fltr�
a dull penally of not more than Dve hundred dollen,(SrW).j:
E]1. �SyjAKJF�S ❑
I,as owner of the property,or ea my empayewith wages as their safe compensation,will do r�
tiro work,end the structure Isnot Intended or offered for eels Sc.e7044,Buslnese and Praise- Vim.
skins Code: The Contractors License Law dam not apply to on owner of property who bullde or WOOD SHINGLES ❑T
Improve,thereon,and who employees,provided such work himself or through his own emprovided Met
such Improvements are Trot Intended or offered for sale.If,however,Me bulkflrg or Improvement
4 soldwlthln one year of completion,the owner-builder wlU have the burden of proving that he did OTHER(SPECIFY)
j-NCDX,
not Wlkf or Improve for purpose of salsa).
D 1,as Amar of Me property,am exclusively contracting with licensed conlrectars to cautruct 7
Me project(Sec.7044,Business and Professions Code:The Contractors Gears Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owmer of property who builds or Improves thereon,and who contracts for such projects
with a conlrectcr(s)Ik nsad pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
711 am exempt under Sec. ,B&P C.for MIs reason
owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaratlon:
D 1have and will maintain a Certificate of Consent to self41murs for Workers Compensation, Z / Od BUlldln 2�'L
as provided for by Section 3700 of Me Labor Code,for Me performance of the work for which this J/mss /pp ' / / g
r Is i.aued. : LLL –!O /(?y 4/0 0 Seismic 1110
have and will maintain Worker's Campematfon In.urence,as required by Section 37DO of
the or Code,for the performer's of the work for which this pennN Is Issued,My Workers
Compensation Insurance carrIerard Polley number are: �L GQC Total
Carer
PolicyNA) _�`12�I /`••AZ/ PERMIT AUTHORIZATION DATE
-
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATONINSURANCE N.C[]
(This section need not be completed If the penult is for one hundred dollars($100)or leas.)
I certh,that In the performance of the work for which Mls penult Is Issued,I shell wt empty
any person In any manner w m
as to become subtec o Me n Co pe twn Lowe at cao- All roofs shat rbe inspected prior to an roofing material being
fornla. p) installed. If a roof is installed without first obtaining an
Dare/��/! applkam e---•� inspection,I agree to remove all new materials for inspection.
NOT E TO APPLICANT: If,after making MIs Certfigirto of Excurr ,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation pproV.I.ns'of me r Cotla,you must forthwith campty, pP P Y P
with such pmvielons w this permit sha,be deemed revoked: Source regulations. -
I cerGty Met I have read this application and state that the shows Information Is correct I agree
to oonpty with all city and county ordinances and state laws releting to bu5ding construction,and All roof coverings t eclass"C"Or better
hereby authorize rapresentativea of this city to enter upon the above-mentioned property for Io- '
(We)agree to neve,expenses
Indemnifyw and keep harm leas the City of Cupertino mid against Ils,u— y
Judgments,costs and perIL which may In any way accrue against said City In,u—
of URE O APPLICANT DA�
of 9ta Paulin W iNs permit
WrRE-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