R 5284 APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R- 5284
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
RESIDENTIAL COMMERCIAL OTHER
OWNER'S y� HAZARDOUS FIRE AREA
V 1 `1 � l - YES ❑ It yes—I understand that a Class A
NAME oof assembly is required.
r
NO Initial. I.C.B.O.#
ADDRESS KERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S 'V'
NAME�� e�S 1 U�U K��q-q 1�GI (�. TO BE REMOVED r TO BE RETAINED
L�
ADDRESS336 S �� �� 5�,., TYPE OF ROOF COVERING
CITYBZIP
EXISTING
PHONE n"Q Q5—/,qs�
BUILT-UP ROOFLICENSE
❑
NUMBER /a 4� 3 1>-17p— ASPHALTSHINGLES ❑
LICENSED CONTRACTORS 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. !' / / WOOD SHINGLES ❑
License Class� Lie.Number
Date a1 �'7—S Conbactor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that I am exempt from the Contractor's License Law for the following reason.
IS
7031.5,Business and Professions Cade: Any city or county which requires a permit to
construct-alter,Improve,demolish,or repair any structure,prior to lis Issuance,also requires the BUILT-UP ROOF El
for such permit to IIIe a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Lew(Chapter g(commencinp with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt t erefrom and the basis for the alleged ASPHALTSHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a clvll penalty of not more than five hundred dollars($500).):
❑t-as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended Or offered for eels(Sec.7044,Business and Profes-
sionsCode:The Contractors License Lew does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year ofcompletlon,the owner-builder will have the burden of proving that he did OTHER(SPECIFY)
not build or Improve for purpose of sale.).
I]I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors 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 contmotogs)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
E]I em exempt under Sec. ,S&P.C.for this reason
Owner Date APP I AT DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: p���se
❑I have and will maintain a Certificate of Consent to eslf-Insure for Workers Compensation, BNlldln 4r J�1
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this DEC - 21996
2 1996 g
th It Issued. W F/ s71'SU �1C� . �— $elsmic
have end will melnteln Workers Compensation Insurance,ee requlretl by Section 3700 of ry b 7
th D Oor Coda,for iha performance of the work for which this permit la laeuetl.My Workers CI 1 1 Uf CUFCI�I IIV� , Total
Com aneetlOn Insurancer�carrier end Pallc number ere:
Oarrler ��'• CERTIFICATE
FROMW �"ysd3'R PERMIT AUTHORIZATION DATE
CERTIFICATE EN EXEMPTION FROM WORKERS' ^
COMPENSATION INSURANCE
(This section need not be completed If the permit Is for one hundred dollars($100)100)or Iese)
I certify that In the performance of the work for which this permit Is Issued,I shall not emtoy
any person In any manner so as to become subject to the Workers'Compensatlon Laws of San. All roofs shall be inspected prior to any roofing material being
fornix' ^�x II t installed. If a roof is installed without first obtaining an
Date /a —9 Applicant 11 c; g.—L Q- 'dW inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will cora
subject to the Workere Compensation provisions of the Labor Code,you must forthwith comply pP ply with all non point
with such provisions or this permit shell be deemed revoked. Source regulations.
I comfy that I have reed this application and stats that the above Information Is correct.I agree
to comply with ell city and county ordinances and state taws relating to building construction,and All roof coverings to be class"C"or better.
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 Ilabliltles, , �w+A-+ 'll ;JA
)uogmems,costs and expenses which may In any way accrue against Bald City In conaequen<e
of the granting of this permit. SIGNATURE 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY