R-5657 PERMIT R_
• APPLICATION FOR CITY OF CUPERTINO NUMBER 5657
INSPECTION DIVISION PERMIT EXPIRATION
'-� REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS ,4I (1�I
2 ✓ ` I�� N`� l RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
U 1 � �e �� 2� 1 I VES ❑ It Ye
sa d that a Claw
NAME �� root assemdy is required.
NO Initial I.C.B.O.11
ADDRESS " '__J1 EXISTING ROOF COVERING
PHONE `'1 _ 3 C7 NUMBER OF EXISTING COVERINGS
CONTR �TOR'S
\� �� t FG/ TO BE REMOVED TO BE RETAINED
NAME J I lJ
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP 1o,SZ 1 Q. IS2
�j EXISTING
PHONE ( 2 — �- )-D
BUILT-UP ROOF ❑
LICENSE ``� ❑
NUMBER SC-,.S't- 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 lull force and
effect.
�? c 6 �4 3 WOOD SHINGLES
License Class Llc.Number J
Date Contractor , tOTHER(SPECIFY) 7
/
OWNER-BUILDER DECLARATION PROPOSED Li
hereby affirm that am exempt from the Contractor's License Lew for the following reason. C
(Sec.70315,Business and Professions Code: Any city or county which requires a permit to
applicant
construct.alter,Improve,demoto file signed airstatement
any structure,Is licenor tose Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit a IIIA a signed r 9(comm that g Is licensed pursuant to the provisions
of the ss an Pre License Lew(Chapter a(commencing with Section 7000)of Division 3 le the
exemption
entl violation of Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Anyviolationotmoe than
five 7031r by any applicant fora permit subjects the applicant to
e civil penalty of not more man five by employees
dollyeesrs(h wag): WOOD SHAKES
❑I,ad owner of the property,or Ceded oyeeewith wages estheir sole compensation,sandwill ❑
the work,and the structure Is not Intended or offered for Halo(Sea owner
of Business entl builds
o-
sionsCotle:The,antrailhod License Lawdoes elf apply to or
hiso n employers,who buildsor WOOD SHINGLES ❑
Improves thereon,entl who does such work himself or through his own employees.Improvement that `
such Improvements are not completion,
or offered for sale. ill however,the en of pr or Improvement 1
Is not bit ld or I prove for purpose
s iha ownerbuiltler 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,em exclusively contracting with licensed contractors to construct
the project(SBc.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 contraclor(s)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS,
I]I em exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICA: =VALUATIONPERMIT FEE
WORKER'S COMPENSATION DECLARATIONI hereby affirm untler penalty of perjury one of the following declaration:
❑I have antl will maintain a Certificate of Consent to selbinsure for Worker's Compensation, �� Buildin�ee provided for by Section 3700 of the Labor Code,for the performance al the work for which thispermit is issued. Seismic`7:❑I have and will maintain Workers Compensation Insurance,es required by Section 3700 of /�_the Labor Code,for the performance of the work for which this permit Is Issued.My WorkersC�TyUf Compensat�io`nIInn/suurrraance carrier andnd Policy number are: LUp6Hr Total
Carrier J `—r�� 1 U ' PollcyNo. J 1" PERMIT rAIUTDATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed It the permit is for one hundred dollars(8100)or leas.)
I certify that In the performance of the work for which this permit Is Issued,I eheli not employ
any person in any manner so as to become subject to the Workers'compensation Laws of call- All roofs shall be inspected prior to any roofing material being
fortla. installed. If a roof is installed without first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
subject
i.the Workers'Compensation n provisions ofetheflcate of Labor Code,Exemption,
musushould become
forthwitth comply Applicant understands and will comply with all non point
with such provisions or this permit shalcbe 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 reteting to building construction,and—^ AlIToe coverings be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property far In.
sp(We) purposes. 1. _ 43-/ L -97
(We)agree s save,Indemnify and may I harmless the City ai Cupertino against liabilities,
judgments,the gran costs and expanses which they In any way accrue against said City In consequence
of me granting of this permit. ----MNATURE OF 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 _