R 5286F_ 1
L i
11
OFFICE COPY
PERMIT R- 5286
APPLICATION FOR CITY OF CUPERTINO BER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1 SO DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S / /
/5 a�
HAZARDOUS FIRE AREA
YES ❑ It I that Class A
'<;7104L� .
NAME ���///"'
yes — understand a
root assembly is required.
NO ❑ Initial LC.B.O.11
���/C �i�Cet�
ADDRESS J2
EXISTING ROOF COVERING
PHONE 93/
NUMBER OF EXISTING COVERINGS l
TO BE REMOVED / TO BE RETAINED
CONTRACTOR'S D
NAME 4ST� �OGL/��7
ADDRESS C _ / / „ 9�3
�rGN.7 •7f+'7AS
TYPE OF ROOF COVERING
rCITVBZIP 0
EXISTING
PHONE
❑
BUILT-UP ROOFLICENSE
745
NUMBER '^"
ASPHALTSHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby afflrm that I em Rinsed under provisions of Chapter 8 (commencing with Section
WOOD SHAKES
7000) of Division 3 of the Business and Professions Code. and my license Is In full force and
effect. &I A7 i 7G
WOOD SHINGLES
License Claes Lic. Number
7 gG
'
OTHER (SPECIFY) ❑
Date Contractor
OWNER -BUILDER DECLARATION
hereby affirm that I am exempt from the License Law for the following
PROPOSED
(Sec. 70315, ,Improve antl ermitreason.
in Professions e: Any city
Code: Any city or county which requires a permit to
olish,orrep prior lolls issuance, the
apapplicantdfileasignedtaany
BUILT-UP ROOF ❑
licant,alter, suImprove. talso o
h for such permit to flaw a signed mentrthate,
that he ticermea pureuenf to the provolone
of the
of t Co License Lew (Chapter
r 9 (comm it
(commencing with Section 7000) of 3 of the
'
end
ss and h for he
Code) or that h Is exempt therefrom and the hale for the alleged
ASPHALT SHINGLES ❑
exemption violation of
exemption. Any violation of alin r by any applicant for a permit subjects the applicant to
a civil penalty of not more than hundred
live hundred dollen with wag.):
❑I,ae owner ofthe property, wegee as their sole compensation, wolfs.
WOOD SHAKES ❑
t i to dedemployeeswith
the work, e: the structure Is not Intended or offered for Isle (Sec. 7044, and o-
nionsCode:Th,anw hodLlceneeLewdosenotapplytoenownerofpropertywhobuildsor
property builds
Improves thereon, and who does such work himself or through els awn employees, provided that
WOOD SHINGLES ❑
o
Isco improvements are not Intended or offered for leer. I( however, the en Of r or Improvement
doingor
hinowner -builder will have the burden of proving that he tlld
Issoldbuild
build Improve
�� `
OTHER (SPECIFY) f� ✓
not or prove for purpose of sthe
or for purpose of sale.).
❑ 1, 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 doge not
PROVIDE I.C.B.O. REPORT NO. %�
apply to an owner of property who builds orlmproves thereon, and who contracts for such projects
with a contractor(a) licensed pursuant to the CPontractors License Law.
C]I am exempt under Sec. ,B 8 P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Dem
WORKER'S COMPENSATION DECLARATION
APPLICATION DATEI
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ 1 have and will maintain a Certificate of Consent to self -Insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
per Ile Issued.
�g ®
�/
Building
I have and will maintain Workers Compensation Insurance, as required by Section 3700 of
t L bar Code, for the performance of the work for which this permit is issued. My Worket'e
^W�y�/
s�(�
$eISmIC
Compensation Insurance carrier and Policy number are:
��
Total
Carrier �r¢7Z rrs�1/7 Policy A5 7/- 9G
No.
PERMLTiATHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed if the permit Is for one hundred dollars (5700) or leas.)
I certify that In the performance of the work for which this permit is Issued, I shell not employ
All roofs shall be inspected prior to any roofing material being
any person In any manner so as to become subjy.te•4 w workers' g nsatlon Laws of
forma. L_
/-ZL -QG
installed. If a roof is installed without first obtaining an
Data Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE APPLICANT: If, after mkinthKof rxemo
subject to theOWorrkers' Compensation rovisions of theflLabor Code, cate yoeu must fo thwllthbecome comply
Applicant understands and will comply wit all non point
shaft deemed revoked.
with each ,hat
onshave
or thispermitapplication
SOUfC/ lotions.
I
I tangly mellhave reedountyordinances state that the above Information Iscorrect.agree
to complythorze with all and county of this cls and construction, and
All r C Irl IasS " or better.
rep se ter utate pon bove- albino
hereby authorize representatives of this sly to enter upon the above-mgntlonetl property for In-
the
toe.
ap We) agree save, Indemnify and keep nayway the City of Cupertino against Il
(We)ts,co
I�—ZL �Q4i
s -----es,
judgments. coats and expenses whim may In any way accrue against said City In consequence
of the granting of this permit.
SIGNATURE 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