R 5813APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5 813
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228/PERMITEXPIRESIFWORKisNOTSTARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
COMMERCIAL OTHER
—
OWNERS r
NAME ,.V(L�������/�/�
ADDRESS
A ('� 5 a--vO V �V �.
NAME_U_ UJ In
ADDRESS)/�'T
CITY B]IPh I lS ✓ill ft V`p Is�
358--1233 9S/I z
PHONE
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is I to I force and
effect.
License Class Uc. Number
Date Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that 1 em exempt from the Contracefs License Lew 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
applicant for such permit file le eel nater lean (commencing
pp P g e el he s licensed pursuant to the provlelana
of the ss and Contractor's License Law) or tat 9 (commencing therefrom
Section 7000) of for the ale the
Business end violation of Code) or that he le exempt antor and the seals for the applicant
to
exemption. Anyviolationo t more
of Section hundred
by any applicant for a permit subjects me epplieam to
e civil penalty of not mora loan live hundred tlollare ($500)J:
❑ 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 Profes-
slons Code: The Contractors License Law does not apply to an owner of property who bullds or
Improves thereon, and who does such work himself or through his own employees, provided that
such Imme,,... Me are not intended or offered for sale. If, however, the building or Improvement
Is sold within one year of completion, the owner-bulider will have the burden of proving that he did
not build or improve for purpose of sale.).
❑ I, as owner of the property, em exclusively contracting with licensed contractors to construct
the project (See. 7044, Business and Professions Code: The Contractor's License Lew does not
..apply to an owner of property who builds or Improves thereon, and who contracts for such projects
with a contractors) licensed pursuant to the Contractors License Lew.
❑ I am exempt under Sec. ,B a P. C. for this reason
uwner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
Ej I have and will maintain a Certificate of Consent to self -insure for Workers Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit is Issued.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
the Labor Code, for the performance of the work for which this permit Is Issued. My Worker's
Compenss (Ion Insurance carrier end Ilcy umiteer ar n {�Q�
Carrier l//�%e�l��f��T�"^hPcy No5ryRQ S� 1 /r
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the permit Is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which Nis permit Is Issued. I shall not employ
any person In any manner so as to become subject to the Workers' Compensation Laws of Cali-
fornia.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
with such provisions or this permit sbalQbe deemed revoked.
I certify that I have reed 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
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 liabilllles,
judgments, costs and expenses which may in any way accrue against said City In consequence
PLYWOOD:
INSP. _
BATTENS:
INSP. DATE
YES ❑ "IS -
i yes — I understand that a Class A
mot assembly is required.
NO ❑ Initial I.C.B.O.
NUMBER OF EXISTING COVERINGS
TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
EXISTING
BUILT-UP ROOF ❑
ASPHALT SHINGLES
❑
WOOD SHAKES
WOOD SHINGLES
OTHER (SPECIFY)
❑ /
EP. A 0 n
PROPOSED
BUILT-UP ROOF 20 Affil
ASPHALT SHINGLES CI wrtril nNJ
WOOD SHAKES ❑
J/El
WOOD SHINGLES ❑ .
OTHER (SPECIFY) - ❑
PROVIDE I.C.B.O. REPORT NO.
PROVIDE MFGR. INSTALLATION SPECS.
(APPLICATION DATEI VALUATION I PERMIT FEE I
p' 700
Seismic
O Total
PERMIT AUTHORIZATION I DATE I
Ali roots Brief De Inspected prior to any roofing material being
installed. If a roof is installed without first obtaining an
inspection, I agree to remove all new materials for inspection.
Applicant understands and will comply with all non point
source regulations.
All roof Down ngs to be class "C" or better.
SIGNATURE OFAPPLICANT- DATE
FINAL:
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION - I
OFFICE COPY _