R 5023 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 5023
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS /�_"
l062 S� Gt,/� /7 0 P1,h(.0-- RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
���� C YES ❑ It yes—I understand that a Class A
NAME J roof assembly is required
'/ NO E] Initial I.C.B.O.ft
ADDRESS /4 7,l ✓AK MVQ� SV t afI l0� EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S '
NAME Sova �l U,4II4e t. �i n q Lp TO BE REMOVED TO BE RETAINED
ADDRESS9� 9 C�-���/ ¢SSa- /EffO �SSr r/'S7 T-YPEOFROOFCOVERING
CITY&ZIP
1000
PHONE LQ00 — 705- - 266.7 BUILT-UP ROOF
LICENSE —7O S—D O
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby affirm that I em licensed under provisions of Chapter a(commencing with Section WOOD SHAKES [ �
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
License Class G 9 UINumber 7050570 WOOD SHINGLES 9r�sI
Dale 7 ?G Contractor OTHER(SPECIFY) JUL ^ V 1996
OWNER-BUILD v CLARATION PROPOSED
I hereby affirm that I am exempt from the hactor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to CI lY UrtilO:H I IIVI)
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 g(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 ®/
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($51
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure IB not Intended or offered for sate(Sec.7044,Business and Plates-
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
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
Is sold within one year of completion,the owner-builder will have the burden of proving that he die OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code;The Contractors 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 contractoye)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to seibinsure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this n
permit01 Is Issued. / DO Seismic
❑ have and will the performance
Worker's Compensation the work
Insurance,as required by Section 3700 of ///"^"" ^
.the Labor Code,for the performance of the work ra which info permit Is Issued.My Worker's Total
Compensation Insurance center and Policy number are I ^� q 9
Carrier S'/-k it FVnIQ Policy No../y OU 79O Z•� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N,C.O �a /
(This sectlon need not be completed If the permit Is for one hundred dollars($100)or lees.)
I certify that In the performance of the work for which this permit Is Issued,I shell not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali. All rofWs 9hall be inspected prior to any roofing material being
fornia, j� /��� installed. If a roof is installed without first obtaining an
Date_L�' t� Applicant inspection,I agree to remove all new materials for inspection.
subject to TICEETO Athe WOPrWfk�eraCCampernaetlon p after m klecome
alone oltneflLebacate�Cademyalu muetufo thwlthbcomply Applicant understands and will comply with all non point
with such provisions or this permit shapbe deemed revoked. SOUTC@ regUl@IIODS.
I certify that I have read this application and state that the above Information to 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 enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities, , ZG
judgments,mats and expenses which may In any way accrue against said City In consequence
of the granting of this Permit. N TURE OF APPLICANT DA E
PRE-INSPECTION: PLYWOOD: 1491 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