R 5833 PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 5 8 3 3
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• BUILDING ADDRESS 180 DAYS FROM LAST CALLED INSPECTION.
A. ►/y1�n
102l N�I ZCI o!l Ove, RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
//)� YES ❑ 11 yes—I understand that a Class A
NAMIS�RC %n i' E I e�.�kk. Co • roof assemby Is required.
NO ❑ Initial I.C.B.O.#
ADDRESS /02101 ZynjQ C1AL AVR, EXISTING ROOF COVERING
PHON O V26Z-.5'6o4 NUMBER OF EXISTING COVERINGS Yme
CONTRACTOR'S n
NAME�I�U�1 KO�I /*f I" SV.5JC*V15 TO BE REMOVED ��S TO BE RETAINED
ADDRESS / -'^ 1/• 5 �W C-•t ��//2 T_YPEOFROOF COVERING
CITY&ZIP 10 / /�� JJ
EXISTING
PHONE�( e� a 1 _/C 7llrn BUILT-UP ROOF .
LICENSE So2
NUMBER p O _ ASPHALTSHINGLES ❑
J
LICENSED CONTRACTORS DECLARATION ❑
I hereby affirm that I em licensed under provisions of Chapter g(commencing with Section WOOD SHAKES C
7000)of'Division 3 of the Business and Professions Code,and my license Is In full force and
effect. �1 �f
License Clasiy—mss 4C-711 UI .Number ,'50'2 (290 WOOD SHINGLES ❑
1),.1.2-3F 98 ContrI$IFi([NIS OTHER(SPECIFY) El -
OWNER-BUILDER DECLARATIO PROPOSED
I hereby affirm that I am exempt from the Contractors License Low 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 fila a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Lew(Chapter 8(commencing with Section 7000)of Division 3 of the
• Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).): (4
C]1,as owner of the property,or my employees with wages as their sole compensation,will doWOOD SHAKES ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profen-
slons Code:Th Contractor's License Lew does not apply to an owner of property who builds or WI)LES C.B
Improves thereon,and who does such work himself or through his own employees,provided that 'tui 11+L1 LES ❑
such Improvements are not Intended or offered for sale.It,however,the building or improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did so
CHER(SPECIFY) ❑
not build or improve for purpose of sale.), i1
❑I,as owner of the properly,em exclusive contracting with licensed contractors to construct +` y
the project(Sec.7044,Business and Professions Code:The Contractors License Lew does not P
apply to an owner of property who While or improves thereon,and who contracts for such projects G�,`ROVIDE LC.B.O.REPORT NO.
with a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
EJI am exempt under Sec. ,B&P.C.for this reason
OwnerData
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I
I hereby affirm under penalty of perjury one of the following declaration: 15 27 ao
1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this �� BUI dog
permit is Issued. SejBmiD D
lsyl have and will maintain Workers Compensation insurance,as required Section 3700 of 0
-the Labor Code,for the performance o1 the work for which this permit Is Issued.My Workers �_Zy -9g 5 1 Z5 °
Compo alien Insurance carrier end Policy number are: , Total
Cerrlerlic_- Policy No. n�Z970 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXE PTION FROM WORKERS'
COMPENSATION INSURANCE N.C❑ a f pn
(This section need not be completed if the permit is for one hundred dollars($100)or less.) �rr 1 `^
I certify that in the performance of the work for which this permit Is Issued,I shall not employ Y v
any person In any manner se as to become subject to the Workers'Componsanon Laws of can All roofs shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOT
OLseimaking
Exemption,
should become
subject t.the Worrkers'Cmpeno provisions of the Labor Cpe,you mulorthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shalQbe deemed revoked. source regulations
I certify that I have read this application and stale that the above Informadon is correct.)agree �" ,,
to comply with all city and county ordinances and state laws relating tobuilding construction,and QNAST�UREF,
of coverings to be aSS y,Or flet.
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,
lucgmants,costs and expenses which may.In any way accrue against said Cly Inconsequence
at the granting of this permit. - OPLICANT 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
_. OFFICE COPY