R-5391 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5391
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (40$)777-3225 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN fall DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA
YES ❑ II yes-I understand that a Class A _
NAME !� �r/'LC LY/11�CX.�� It assembly ismquired.
NO Initial I.C.B.O.q
ADDRESS � • `J I " "� I EXISTING ROOF COVERING
PHONE q.Z NUMBER OF EXISTING COVERINGS
CONTRACTOR' p
NAME
J ,(/ � TO BE REMOVED TO BE RETAINED
��/T
ADDRESS ,! �J Q O� TYPE OF ROOF COVERING
CITY&ZIP TSO �Q�'1. T -6 EXISTING
PHONE ��3—G.3 7� BUILT-UP ROOFLICENSE
❑
NUMBER 2700 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES L
7000)of Division 3 of the Business and Professions Code,and my license Is in full force and
ane°L y/ 2 r WOOD SHINGLES El
License Cles f,5✓ Lie.Number I 0 0p,
Date Coal star OTHER (SPECIFY) E] /
OWNER-BUILOFF DECLARATIOWPROPOSED y®
I hereby affirm that I am exempt from the Contractor's License Law for the following reason, p '
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to ^I /�
construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UPR 0 ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the tea{ y� Tipp(2!
• Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHAINGLES` �`ns �l"y7 - •'
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars($500).): WOOD SHAKES�UMt
0
�ry
❑ tSY
l,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 Profen 4
sions Coda: The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES V ❑
improves thereon,andwho does such work himself or through his own employees,provided that - Q /—. ,. -
nsuchimprovementsarenotintentletlorownetlforsale.illhowever,the building oiimprovement OTHER(SPECIFY) <J Ll CJx^-��
sold within one year of completion,the owner-builder will have the burden of proving that he did l]d
not build or improve for purpose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project Isom.7044,Business and Professions Code:The Contractor's License Law 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 contractors)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 Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of the following declaration: ^/
❑ have and will maintain a Certificate of Consent to self-insure for Worker's Compensation,which
Building
as provided for by section 3700 of the labor Code,for the performance of the work for which this !�y! / l` 0
perm' 's issued. ! y Seismic
��})have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Cotle,for the performance of the work for which this permit is Issued.My Worker's
'Compensation Ins n carrier and Policy number are: Total
Carrier ��^^�� Policy No,-? ^� 7 7�� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C❑ LA1
(This section need not be completed It the permit is for one hundred dollars($100)or less.) t 1
I certify that in the performance of the work for which this permit Is Issued,I shall not employ
any person in aryry''manner so as to become subject to the Workere Coy�ensation Laws of Cali. All roofs shall be Inspected prior to any roofing material being
formData� /fes) /A installed. If a root is installed without first obtaining an
Data �� Applicant f� y�y ,FI`����" —� inspection,I agree to remov w materials for inspection.
subecct to Ele Workers Compensation ANT. 11,after provisi ns aft.Labor Codelicate of myou must fothwithb-seems
comply Applicant underst,410ks and will comp with all non point
with such provisions or this permit shalGbe deemed revoked. Source regulatio
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 builtling construction,and All r: CQV>L'rbe ClI after
hereby authorize representatives of this city to enter upon the above-mentloned property for In- C/�/(/
spoctlon purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities, �! /
judgments,costs and expenses which may in any way accrue against said City In consequence
of me grading of this permit. SIGNATOR F APPLICANT 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