R-5706 APPLICATION FOR CITY OF CUPERT.INO
NUMBER PERMIT
R- 5477
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 nn X/
10 Ip-7C uW#0 qm RESIDENTIAL / _COMMERCIAL OTHER
OWNER'S _ HAZARDOUS FIRE AREA
2 \7( f� VES _ If yes—I understand that a Class A
NAME �'1_ /v L" roof assembly is required.
_ ,n / NO _ Initial I.C.B.O.A
ADDRESS S'p I. �b K A—e-oV E EXISTING ROOF COVERING
PHONE — C4
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S` / �y (J (� ,,
NAME SIU1 / Y`7L)`e 2000 /tic TO BE REMOVED TO BE RETAINED
ADDRESS 1 1�`V .YA 0� LOM A �y v ;t l q a LIQ TYPE OF COVERING
CITY aZIP Vt flf-t tr V `T /'1 EXISTING �
PHONE � y, BUILT-UP ROOF �
LICENSE
NUMBER ASPHALT SHINGLES ❑
C ED ONiTORE DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is in full force and
effect. -3 _ _ _ ,
WOOD SHINGLES ❑
License Claes � Uc.Number
Date Contractor
t)- S I Eth.11frr✓�/V OTHER(SPECIFY)
^ y�
OWNER the LDER DECLARATION PROPOSED OCThereby affirm that am exempt from the Contractor's License Lew lar the following reason. CT 4] 9
(Sec.construct,
It r,improve,
and Professions it any Any city or county which requires a permit to / /� 19(17
applicant
alter,improve,to file signed statement
structure,Iprior to s
issuance,also reproves the BUILT-UP ROOF ❑ IA.J7
applicant lar such permit to Ilia a signed statement that he le licensed pursuant of
the provisionsothBY,
of the Contractors License Lew(Chapter B(commencing with Section 7000)of for the 3 0l the j
. Business and Professions Coda)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031r by any applicant for a permit subjects the applicant to
e civil penalty of not more than,or hundred dollars(h wag 1: WOOD SHAKES
❑I,as owner althe property,or tmy eemployee.with wages estheir sole compensation,will ❑
the work,and the ontr structure Is not Intended or offered for cele(Sec.7044,Business entl wilds or
improves
Code:The Contractor's License Lawdoes himself apply to an or
hiso own
property es,who buildsorWOOD SHINGLES ❑
improves thereon,and who does n such work himself or through his own employees,Improvement ed that
such Improvements are not intended or offered for sale. ill havethe the en of pr or Improvement -
nosold tbuldori prove aroloompletof sale.).owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of aele.).
I,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 Law 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 Law. PROVIDE MFGR.INSTALLATION SPECS.
I am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑ have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation,which
this ' OI 00`l Building/��,d0
as Fl I have
for by Section 3700 of the Labor Code,Consent
the performance for
of the work for which this (f v
permit is Issued. � Seismic
❑ have and will the pert Workers Compensation Insurance,as required is i u Section 3700 of
the Labor Code,for the performance of the work for which this permit is Issued.My Workers / O
Compensation Insurance carrier and Policy number are: 52
/ /1/^S� Total /
Carrier 074 r`, w rJP policy No. 21 1u—I D)" ! PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.0
(This section need not be completed It the permit Is for one hundred dollars(5100)or las..) FF �� p (O�4�'q
1 certify that in the performance of the work for which this permit Is issued,I shall net employ a \\\ 1
any parson In any manner so as to oecome sublet o the workers'Compensation Laws of Cain All roofs shall be inspected prior to any roofing material being
fornla. /A installed. If a roof is installed without first obtaining an
Date 41 Applicant inspection,i agree to remove all new materials for inspection.
NOTICE APP CANT: If,after making this Certificate of - ayptfon,you should b oma Applicant understands and WIII comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you.must forthwith imply P Y p
with such provisions or this permit shafQbe 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 roo coverings to be class"C"or .etter.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes. �^
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, J
judgments,costs and expenses which may in any way accrue against said City in conaepuence SIGNATURE OF APPLICANT ATE
of the granting of this permit.
• PRE-INSPECTION: PLYWOOD: IWPROGRES
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