5686 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 5686
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1130 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS /
OS�J3 tSa?v\1r.1E DACE' RESIDENTIAL V COMMERCIAL OTHER
OWNER'S GHAZARDOUS FIRE AREA
A S1 �N V Cti d' —+.L.ga
YES ❑ If yes s I mblyisrunderstand that a Class A
NAME
root assembly s required.
NO Initial I.C.B.O.a
ADDRESS1Os33 �SQu�scF �LACC EXISTING ROOF COVERING
'PHONE OS r M�O- O 3871 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S (�
A M S3 rigs
DE��LOrME1�i TO BE REMOVED TO BE RETAINED
. B�
NAME(� � O.l
ADDRESS ^^ TYPE OF ROOF COVERING
clry a zIP S1 w3 C �Frsaiamoa�"'C 3 S.7 9 51?3
EXISTING
PHONE` iPf�) =-91+84" BUILT-UP ROOF ❑
LICENSE
NUMBER 3$'t55/o ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
affect. WOOD SHINGLES ❑
License Class Rli Lt..Number Alfil SS'
Data Contractor
�A0191 � OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATIOfTPROPOSED
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 9(commencing with Section 7000)of Division 3 of the 7
• Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exempti(n.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).):
❑I,as owner of the property,or my employees 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-
slons Coda:The ContraWOOD SHINGLES ctor's License Law does not apply to an owner of property who builds or
Improves thereon,end who does such work himself or through his own employees,provided that E]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.). si
Ej I,as owner of the property,am exclusively contracting with licensed contractors to construct �4t�C
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO. D�az E
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractere)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
C]I am exempt under Sec. ,B Is P.C.for this reason P
AIn
Owner Data
WORKER'S COMPENSATION DECLARATION APP [CATION DATE VALUATION PERMIT FEE
i
I I hereby affirm under penalty of perjury one of the following declaration: MX LJ8
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, g
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
/ permit is issued. V CCfy
Ui ��Y SeISrn IC
.t ❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 a1
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's $1 Total
Compensation Insurance carrier and Policy number are: `�1 s
Carrier Policy No. 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 tlollars($100)or less.)
I certify that in the performance of the work for which this permit Is Issued I shall not employ
any person in any manner so as to become subject to the Workers'Compenaalion Laws of Call. All roofs shall be inspected prior to any oofing material being
Immo. installed. If a roof is installed without first obtaining an
Data?-la1 4 7 Applicant Mxaald�tjamsl inspection,I agree to remove all new materials for inspection.
subject to the'
OWorrkers Compes of the
11,T. after
n provisionlLaborr Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed 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 coverings to be class"C"or better.
hereby authorize representatives of this city to anter upon the above-mentioned property for in-spection purposes.
oand 7
(We)agree to save.indemnify and keep harmless the City of Cupertino against liabilities, 1
judgments,con d expenses which may in any way accrue against said CH,In consequence
of the granting of this permit. SIGNATURE F APPLICANT- DA E
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