R-5241 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 52 41
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN PERMIT ISSUANCE OR
WI HAYSS FROM
LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAI COMMERCIAL OTHER
OVINER'S - HAZARDOUS FIRE AREA
//n YES C) It yes-I understand that a Class A
NAME �L-��O'r'� roof assembly is required.
NO Initial I.C.S.O.#
ADDRESS EXISTING ROOF COVERING
PHONEa S — / 7J NUMBER OF EXISTING COVERINGS
CONTRACTOR'S Q\ J
—y�
r NAME /'y�1�Y/R'A�(.!/7 SCJ 1 `1- TO BE REMOVED TO BE RETAINED
ADDRESS /`yv �� 1, �`� 'A"�aTYPE OF ROOF COVERING
CITY&ZIP f• " ', V EXISTING
• V i Ui b �" P �9 0 D
PHONE $O BUILT-UP ROOF DE]-
LICENSE
ZP 0 (� �o 19 31 ASPHALT SHINGI���R _ 4 RE
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES(1-r
7000)of Division 3 of the Business and Professions Code,and my license is in full torte and VY Uf• INC)effect. IN
121 39 �/ �+' WOOD SHINGLES ❑
License Class Lic.Number C'>
If 7 ' r ElDate 3 Contractor OTHER(SPECIFY)
OWNER-BUILDER DECLARATIg 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 requiresthe BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provism
of the Contractor's License Law(Chapter 9(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 `/A'
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).): SHAKES
❑I,as owner of the property,or my employees with wages as their sole compensation,will tlo E]
the work*and the structure Is not intended or offered for sale(Sec.7044,Business and Profes- J
sions Cotle:The Contractor's License Law does not apply to an owner of property who ouildscr / WOOD SHINGLES ❑�N �
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 t,
is sold within one year of completion,the Owner-builder will have the burden of proving that he did btHER(SPECIFY) ❑
not build or Improve for purpose of safe.).
❑1,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 Lew 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 contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Dale APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
Fj I have and will maintain a Certificate of Consent to sed-insure for Worker's Compensation, V/O Buildin� _
as provided for by Section 3700 of the Labor Code.for the performance of the work for which this ���/ , ^ r cO/'
p�erm)}'Is issued. •//x •J V Belsmic
`t3l[tave end will maintain Worker's Compensation Insurance,as required by Seclion 3700 of
Ih door Code,for the performance of the work for which this permit is issued.My Worker's
'Compensation Insurance carrier and Policy number are: �� -y Total
Carrier ��� �eC6�o. PolicyN0.li' LL q-0� PERMIT AUTHORIZATION DATE
CERTIFICATE bF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
t (This Seclion need not be completed I1 the permit Is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit is issuetl.I shall not employ
any person In any manner so as to become subject to the workers'Compensation Laws of Cell. All roofs shall be inspected prior to any roofing material being
fertile. 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 A Ilcant understands and will om I with all non Olnt
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P Y P
with such provisions or this permit shalgbe deemed revoked. Source regulations. Sir
I certify that l have read this application and stale 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 Coverings to be Ss" etter.
hereby authorize representatives of this city to enter upon the abovo-mentioned property for in-
spection purposes. -I
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities, /F
judgments,costs and expenses which may in any way accrue against said City in consequence
of the granting of this permit. SIGNATURE OF PPLICANT DTE
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