R 5764 APPLICATION FOR CITY OF CUPERTINO
NUMBER R-
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS - /) , / J1(/ ,
"46 VC urDA 4d� RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
�LYES ❑ It yes-I understand that a Class A
NAME roof assembly is required.
NO ❑ Initial I.C.B.O.e
ADDRESS S l4 M L EXISTING ROOF COVERING
PHONE �'3`� r NUMBER OF EXISTING COVERINGS
CONTRq�TOR'S cJ a (\� ,/ _
NAME/ &l T/L-only� Ob r �+�2-V Co .L�L TO BE REMOVED TO BE RETAINED
ADDRESS ,moo 86'x z(/GG k &4,',Ja (- 9s/, l TYPE OF ROOF COV63NG
CITY&ZIP
T / EXISTING
PHONE 210 S/ BUILT-UP ROOF
CENSE
NUMBER / / `� /�� ASPHALT SHINGLES ❑ //�b'
LICENSED CONTRACTORS DECLARATION ,../
I hereby affirm that 1 am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES p(I
7000)of Division 3 of the Business and Professions Code,and my license is In lull force and /T
affect. C J '? 7/ /f`� WOOD SHINGLES ❑
License Claes Lic.Number _
Date G _9 Contractor Q( R l�/1d. 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 signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Lew(Chapter g(commencing with Section 7000)of Division 3 of the
Business and Professions Cade)or that he Ia exempt therefrom and the heels for the alleged ASPHALT SHINGLES ,L"1
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the appllcant to GF
a civil penalty of not more than five hundred dollars 1$500).): WOOD SHAKES PAI
❑I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profea• C Sro
alone Code: The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES JUPJ p O
Improves thereon,and who does such work himself or through his own employees,provIded that
such Improvements are not Intended or offered for safe.II,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) M/+e( lTrYl�
not build or Improve for purpose of sate.).
01,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 Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who ouhds or Improves thereon,and who contracts for Such projects
with a contractor(s)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
E]I am exempt under Sec. ,B 8 P.C.for this reason
Owner oats
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm untler penalty of perjury one of the following declaration:
I have and will maintain a Certificate of Consent to self-insure for Workers Compensation, ,S Building?'Y17 ��
as provided for by Section 3700 of the Labor Code,for the performance of the work lot which thio (7J( .�
per^�i aIssued, Seismic / (94
OIJ have and will maintain Worker's Compensation Insurance,as required
by 3ectlon 3700 of 1 u/,a �Lpt�
ih�La or Code,for the performance of the work for which this permit Is Issued.My Worker's V (l Total
Compensation Insurance carrier and Policy n bar era:
Carrie, '3r�-TE g`� . Policy No.y10602-0/ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) V — dL
I certify that In the performance of the work for which this permit Is Issued,I shell not employ
All roofs Shall be inSpecte prior to any roofing material being
any person in any manner so as to become subject to the workers'Compensation Laws of Cell-
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTsubject ICE to theoWorrkers'Compensation O APPLICANT: proviafter sionls of theflcate of Laborr Code,you mustufoMwld become
lth comply Applicant understands and will comply with all non point
with such provisions or this permit shall be 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 c vert gs to be class A or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In. •-
eD purposes. ,
(We)
(Wen agree toS neve,expenses
and keep harmless the City of Cupertino against liabilities, (� d
of the gmt croste antl expenses which may In any way accrue against said City In consequence
at the granting of this permit, SGNATURE 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY