R 5209 (2) PERMIT R_ 5209
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
' -
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
WI160 DAYS FROM LAST CALLED INSPECTION.
BUILDING�[J'ADDRESS
�u • �/ (j'C� RESIDENTIAL COMMERCIAL OTHER
OWNER'S / HAZARDOUS FIRE AREA
C`/ /�/�/,4 _ I VES ❑ It yea s I understand that. Class A
NAME V b G,y `}- �/! �V roof assembly is required.
NO Q Initial I.C.B.O.#
ADDRESS— S'/ EXISTING ROOF COVERING
PHONE GT' —!ir p ��D�O NUMBER OF EXISTING COVERINGS m
CONTRACTOR'S
/
�r�'` /L� JG , /�L/� �AV� TO BE REMOVED TO BE RETAINED
NAME �r ,J/u �y
TY16E OF ROOF COVERING
CITY 8ADDREZ P!75 `,4"J.Cy xl X1 • s/' �=ear 9Yi� EXISTING
PHONE 4q C,- 777-I2-?Y BUILT-UP ROOF ❑
LICENSE r^
NUMBER J Z 9 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am 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. ' orWOOD SHINGLES El Of �••`� Lie.Number L
�p_pf_� ( OTHER(S ) ElDate Contractor
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.70315,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 ROO�� ❑
applicant for such permit to Ills a signed statement that he is licensed pursuant to the provisions
• of the Contractors License Law(Chapter a(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the basis for the scant to ASPHALT SHINGLE",,"'-
exemption.
civilpeAny violation of Section 70315 by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dollars(SB00)J: 7/
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES (p ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profen.
slons 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 lh rough his own employees,provided that
such Improvements are not intended or offered for sale.IL however,the building or Improvement
Is sold within one year of completion,the owner-oullder 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(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 contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
El em exempt under Sec. ,B&P.C.for this reason
Owner Date
WORKER'S COMA N DATE VALUATION PERMIT FEE
'
L T
I hereby affirm under penalty of penury onene of of th ION the DECLARATION
following tlecleretlon; 1/
❑I have and will maintain a Certificate of Consent to sell-insure for Workers Compensation, T� �� 19 BUlldingl
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Y
permit Is Issued, 11 '
❑ �x $aiamlD
I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of VI� Vf �UrC(-((ilIV on
the Labor Code.for the performance of the work for which this permit Is Issued.My Worker's V
Compensation Insurance carrierandPolicy number are: .�f � Total
�. Carrie �4M-L¢IC1C� Policy NoA16f_ILI AJ._4Q7DIC PERMIT AUTHORIZATION DATE
ERrIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
This section need not be completed If the permit Is for one hundred dollars($100)or lees.) D
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 roofn shall be inspected prior to any rooting mail 56ing
fornia. installed. If a roof is installed without first obtaining an
�— 9
Data O— ,1 Applicant /� /� - .� _ inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT; If,cher making this Certllica a of xemption,you should became
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shalfbe 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 meeting 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,indemnity and keep harmless the City of Cupertino against liabilities,
• judgments,coats and expenses which may In any way accrue against said City In coneaquence w"" / _Y
mthe granting ofthis permit. SIGNATUHErQFAPPLICANI 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFIrF r•.nvV