R 5731 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5731
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
�
oLW.JlI UCCXII'l �Q� ��r RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
/1r I it yM 06 4 „ /r' „rte YES ❑ II yes—I understand that a Class A
NAME wY�l"�+ I I ///���C�✓/��t i ��_�ll Wt'�w1�ArLXwof assembly is required.
Initial I.C.B.O.u
ADDRESS N22si idrildC?, / .WoCC/ P, ,c,
EXISTING ROOF COVERING
I
PHONE &50— NUMBER OF EXISTING COVERINGS l
CONTRALTO 'S - C1
NAME— VI nY i?0S12L�9i TO BE REMOVED I TO BE RETAINED
ADDRESS p,-t_� /�_- (ILO / .D / ( j TYPE OF ROOF COVERING
CITY&ZIP Q/ ( lrLY/ jil
EXISTING
PHONE `OE- 97a-769"7_ BUILT-UP ROOF ❑
LICENSE
NUMBER _ ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION 1
hereby inion that em sines under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 0l the Business and Professions Code,and my license le in full lone and
effect.
License Class y 2
ico0, 9 Lic.NumbWOOD SHINGLES ❑
S �
Data P—I oL-9' contractorer OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
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 sgned statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter g(commencing with Section 700()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
e civil penalty of not more than five hundred dollars($500).):
❑I,as owner of the propotty'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.
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 did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
Q 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 Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contract.for such projects
with a contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
Q 1 am exempt under Sec. ,B 8 P.C.for this reason
Owner oats APPLI T TE VALUATION IT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following dectaratlon: y.,y��
❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, .•®� dtfdin O
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this #'1Gr12
ermit Is issued. Seismic
have and will mel mein Worker's Compensation Insuranco,as required by Section 3700 of I�
-the bar Code,for the performance of the work for which this permit In Issued,My Worker's CITY Vf VUr'EH)Ohl
cc penal n Insurance carrier a Po'cy ritmi are: Total
C
arter htP✓1P.nw 10r Policy No. 0M� 76 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' \
COMPENSATION INSURANCE N.C.Q
(TMs section need not be completed It the permit is for one hundred dollars($100)or leas.)
I certify that In the performance of the work for w ch this permit le Issued,I shall not employ
any person In any manner so as to become.0 .ct the Woreneatlon Laws of Call. All roofs hall nspected prior to any roofing material being
forma' installed. If a roof is installed without first obtaining an
Date " -77 Appioara inspection,I agree to remove all new materials for inspection.
NOT CE TO APPLICANT: Iaftersubject o the Workers'C mpensation proivisions of thethislLaborr Code,cate yoof Exemlu musufo thwlithbcomply Applicant understands and will comply with all non point
with such provisions or this permit shalGbe deemed revoked. Source reQtllations.
1 certify that I have read this application and sate that the above Information le correct.I agree DJ
to comply with all city and county ordinances and state laws relating to building construction,and Allr f veringS,fQ'b ass or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes. �I q
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, ��( //w ,r O�—� /���{ 7
lutlpmente,coats and expenses which may In any way accrue against said City In consequence S G ATURE OF APPLICANT
of the granting of this permit. 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