R 5735 APPLICATION FOR CITY OF CUPERTINO NU BE R- 573
5
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.
BUILDINGADDRESS
I'DIDl'7 14—RESIDENTIALCOMMERCIAL OTHER -
OWNER'S - HAZARDOUS FIRE AREA
NAME LaSSet^r'e YES [3 If yes—I understand that a Class A
roof assembly is required.
T' /� NO ❑ Irabal I.C.B.O.k
ADDRESS I O1o19 II a� ,..�r�IA�I,)j Cuq�ev� ry:j, 9ISOl4- EXISTING ROOF COVERING
PHONE S qql-- 0450 NUMBER OF EXISTING COVERINGS
CONTRACT I1R'S^ � „(
,[n� `_ '_.Nh _r T�,, TO BE REMOVED f TO BE RETAINED S�
NAME f OOGIYI�_{y��
ADDRESS �� a�\y _I,, _ [�^ TYPE OF ROOF COVERING
CITY&ZIP _ Q4`��CLCCji U1•jd'[AYAi —17111
PHONE—►318/9�a- `x+55 BUILT-UP ROOF
LICENSE
NUMBER 5/ G �491851,o ASPHALT SHINGLES
LICENSED CONTRACTORS DECL91RATION
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is In full force and
effect.
�r WOOD SHINGLES
Llcensa Ctesa `� Lic.Numbers�k S�S� I 3�00 (�--
Dare S��I98 Contract.,All .LC�1_Qs�621Zfa� OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors 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,demollsh,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF
applicant for such permit to life a signed statement that he Is licensed pursuant to the provisions
of the• Contractors License Law(Chapter a(commencing with Section 7000)of Division 3 of the P A 1 0 Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
El
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to rr{�rr����p
e civil penalty of not more than five hundred dollars($500).):
❑ WOOD SHAKES MAY 20 uilYJrUI,as owner of the property,or my employees with wages as their sole compensation,will do c.ANc)j i�
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
slons Code:The Contractor's Llcensa Law does not apply to an owner of property who builds or WOOD SHINGLE_pt'
Improves thereon,and who does such work himself or through his own employees,provided that �L�IY Ur' UUt
such Improvements are not Intended or offered for sale.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)
not build or Improve for purpose of sale.).
El
C]1.as owner of the property,am exclusively contracting with llconsed 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. �L. 7O 6 '
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractoga)licensed pursuant to the Contractors License Law.
❑ PROVIDE MFGR.INSTALLATION SPECS.
I am exempt under Sec. ,B B P.C.for this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, Building 127,00
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 1 4K '4�OO
1 5�
ermssSeismic have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
tpLablorlssuod.
Code,for the performance of the work for which this permit is Issued My Worker's
'Compensation Insurance carrier and Policy number are: Total /9 f(t $o
Carrler�ocgo6 C_WrIdaffinillklicyNo. v2rds94o2' PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTIONFROM WORKERS'
COMPENSATION INSURANCE N C.Le
(This section need not be completed 11 the permit is for one hundred dollars($100)or less.) To ���rJwCG.• /S_2,O�O�/
I certify that In the performance of the work for which this permit Is Issued,1 shell not employ l••
any person in any manner so as to become subject to the Workers'compensation Laws of Celb All roofs shall be inspected priorTo any roofing material being
fertile. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I,agree to remove all new materials for inspection.
subjlect ito the Workers'CompeCE TO APPLICANT: fnsation proviafter slonis of theflLaborr Code,cate of yoiu must fo thwGhoUiltlh comply become Applicant understands and will comply with all non point
with such provisions or this permit shalrbe deemed revoked. source regulations.
I certify that l have read this application and state that the above information is correct.l agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to be class"C"Or be r.
hereby authorize representatives of this city to anter upon the above-mentioned property for in.
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may in any way accrue against said City in consequence DATE
of the granting of this permit. SI AT APPLICANT/-
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