R-5836 APPLICATION FOR CITY OF CUPERTINo
PERMIT R- 5836
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHI180 DA S F DAYS S PERMIT ISSUANCE O.
1B0
N
1 FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
63 u/ t'ruM nee L 4a
RESIDENTIAL COMMERCIAL - OTHER
OWNER'S - HAZARDOUS FIRE AREA
�I �J VES ❑ yes—I understand that a Class A
NAME 'MY. /` (�Vl b Pi rg- of assembly Is required. ..
- L NO _ Infted I.C.B.O.;1
ADDRESS / O r 4z!j �(. t:P�p �:vl EXISTING ROOF COVERING
PHONE - NUMBER OF EXISTING COVERINGS
CONTRACTOR'S pp
NAME k �Q lb [� yt (.� _ TO BE REMOVED 2� TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITYaZIP 3160 EXISTING
PHONE 510 — Jfz BUILT-UP ROOF ❑
LICENSE
NUMBER / /. ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section SHAKES ❑
7000)of DNlsion 3 of the Business al Proleeelone Code,end my license is In lull brce and .
.Mal GLES ❑
Lbenes Clew Uc.Number
Date - Contractor �Q . �=a L.T�rJ'd OTHER ECIFY) ❑
OWNER-BUIUDER DECLARATION PROpGSED
I hereby affirm that I em exempt from the Controdore License Lew for the blowing reason.
(Sec.7031.5,Biminem and Professions Code: Any city or county which requires a permit to
construct,eller,Improw,demolish,or repair any strudura,prior to Its Isnuance,else requlrm the BUILT-UP ROOF Eleppllcant for such permit to file a signed statement that he is licensed pursuant to the pmvldons
• of the Coalr=1018 License Law(Chapter a(commencing With Section 7000)of Division 3 of the
Business and Profe elons Coda)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemptlon.Any vicletlon of Sectlon 7031.5 by any eppllcant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollare(S5o0)J: WOOD SHAKES
1,as owner of the property,or my employees with wages m their sole compenswon,will co ❑
the work,end the Sal Is not Intended or offered for sole(Bac.70".Business and Profm-
eionwCode: TheCantroctoesUcense, a does not"ply toanownerofproperty who bdidea' WOOD SHINGLES
❑
Improves thereon,and=does such work himself or through his own employees,provided that
such Improvements we not Intended or offered for sale.It,however,the building or Improvement
Is sold within one year of compbuon,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not bulb or Improve for purpose of sale.).
❑1,as owner of the property,am exciusl contracting with Ilcen al contractors to construct
this project(Sae.7066,Business and Professions Code:The contractors License law does not . 'PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who adlics or Improves thereon,and who eunlrecls for such projects
with a connswor(s)licensed pursuant to the Contractors License Law.
❑I em exempt urMer Sec. ,B a P.C.for thlareaaon PROVIDE MFGR.INSTALLATION SPECS.
owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKERS COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of the following dederetlon: res pp A -
❑I neve and.111 maintain a Certificate of Consent to sell-Insure for Workers Corrpenmtion, P D „s� Buildin
as provided for by Section 3700 of the Labor Coda,for the performance of the work for which this (N
permit Is Iw and �(e f ��QO $eISR11C
❑I have eM wNl maintain Workers Compensation Inwrence,m required by Section 370D of IGD s
the Labor Code,for the performance of the vrork for which this permit is Issued.My Workers °�
Compensad 1 rerw9 Cartier end Policy number are: ` ^� 1 CI /J Total
CerrlenS�A -� _�(�H� Polley No./`Jf?V. V Up.9 UTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.]
(Tins eactbn neetl not be completed 9 the permitisfor one hundred dopars(5100)or less.)
I certlry met In the performance of the work for which this permit Is Issued,I shell rot empioy
any person In any manner w as to become subject to the Workero'Compenmtbn Leve of Ca& All roofs shall be inspected prior to any roofing material being
romla, n installed. If a roof is installed without first obtaining an
Data o —o _ Applicant _/} 0 : Zu ��r� inspection,I agree to remove all new materials for inspection.
sae eoei Ito throw�e as Cor, If6;antunm provisions 1s o�inelLae r Code,you 'you anent became
mply Applicant understands and will comply with all non point
I pe p you must forthwith comply
with each provielona or this permN shell be deemed resaAcetl. SOUfCe regulations. -
I cusAily met 1 have read this eppllcatkon and state that tho ebovs Information Is cwre0.I agree
to googly width all cry,and cuunry ordinances and stale Tawe rsiating to bulbkg conakudbn.and All roof coverings to be class"C"or better.
hereby authorize representairwa of this dry to enter upon the above-mentraned property icr In- / ^ 9
ep ctillon(We) purposes. !7 ;Z-7 V` <1y
v Cry 2
dpiWe)agree to save, Indemnlry send keep harmless the Clry of Cupertino against IleWlldss, L� � L 7
• 41 tFmews.
epee iu^g o and
oe�ii "�'Im may in anyway accrue egemet sob city In caneequence SIGNATURE OF APPLICANT ATE
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
OFFICE COPY