R-5129 PERMIT R_
APPLICATION FOR CITY of CUPERTINO NUMBER 512 9
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
rCu�e �•gt-ni
Q l0 �Qn 'jam RESIDENTIAL COMMERCIAL OTHER
OWNE 'S V I HAZARDOUS FIRE AREA
NAME 7 Leo n k J`Cl 9 YES ❑ If yes—assembly
is andreq that. Class A
roof assembly is required.
�7
/ N Initial I.C.B.O.u
ADDRESS Lv/O,y )4&3"J , LQ/Za EXISTING ROOF COVERING
PHONE D 1 1—
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S /�
lDeAn n y S (fix .jv� C�61_01L TO BE REMOVED 0. TO BE RETAINED
NAME
ADDRESS p / ' R) C� /��''•��-�tip. TYPE OF ROOF COVERING
CITY&ZIP I�e� / k�`�«4
CcF •950/� EXISTING
PHONE 4409 BUILT-UP ROOF ❑
LICENSE
NUMBER I3 6 6 9 ? J 8j X-6 ASPHALT SHINGLES q10
(
LICENSED CONTRACTORS DECLARATION
hereby affirm that em licensed under provisions of Chapter g(commencing with SectionWOOD SHAKES
]000)of Division 3 0l the Business and Professions Code,
a.andentl my license b and
In lull force entl
effect' WOOD SHINGLES
License Classy Lip.Number Eo� 99 1
»�,i LvA OTHER(SPECIFY)
Date Contractor p
OWNER-the Conn DE Contractors
Lice ION PROPOSED ��
hereby affirm that am exempt from the e: Any
License Law for the following reason. D
(Sec.7031.5,Business and Professions Code: Any city pr county which requires a permit to
construcapplicant alter,for
improve,demoto file signed air statny ement that
priortoits Issuance,alsoreprovisthe BUILT-UP ROOF L+�� �
applicant for such permit to lila a signed etetement that he Is licensed pursuant to the provisions
• of the Contractors License Law(Chapter B(commencing with Section]000)ofDIA Ion 3 01 lbs
Business and Professions Code)or that he IS exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section]031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).): ��rYG
WOOD SHAKES 6 ,I,
❑I,as owner of the property,or my employees with wages as their sole compensation,will do LJ
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes. `
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑ � : lQ
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 ��qq��
is sold within one year of completion,the owner-builtler will have the burden of proving that he did OTHER(SPECIFY) /�- H.G✓7 7.A.
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 Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.�q
apply to an owner of property who builds or improves thereon,and who contracts for Such projects
with a contractions)licensed pursuant to the Contractors 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 penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, BUlldln
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is Issued. i Seismic
❑1 have entl will maintain Workers Compensation Insurance,as required by Section 3700 of 1 0/I
,the Labor Code,for the performance of the work for which this permit Is Issued.My Workers I ` (.�• Total
Compensation Insurance carrier and Policy number are: )
Carrier Qi GLM-� T—,4.� poficyNo. NaC 4�3b PERMIT AUTHORIZATION DATE
CERTIFICATE O EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section 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 shall not employ
any person In any manner so as to become subject to the Workers'Compensetlon Laws of Cell. All roofs shall be inspected prior to al roofing material b ing
forma, 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: It,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensaflon provisions of the Labor Code,you must forthwith comply pP P Y P
with such provisions or this permit shal lue 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 enter upon the above-mentloned properly for in.
spathes purposes.
Pte/we) Y.
(We)agree to save,indemnify and keep harmless the City of Cupertino against Ilabilltlas, -?lo/
judgments,costs and expenses which may In any way accrue against said City In consequence SIGNATURE OF APP ANT DATE
of the granting of this permit.
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