R 5732 APPLICATION FOR CITY OF CUPERTINO NUMBER R" 5732
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
O l
-
100(n RESIDENTIAL COMMERCIAL OTHER
OWNER'S 1 . HAZARDOUS FIRE AREA
NAME�Sdd[ 6'Lit,
I `WILQ YES ❑ It yes—I understand that a Class A
roof assembly is required.
N Initial I.C.B.O.N
ADDRESS ��ej EXISTING ROOF COVERING
PHONE (ASO- low N MBER OF EXISTING COVERINGS
CONTRACTOR'S S� RM ^ g TO BE REMOVED TO BE RETAINED
w7L
ADDRESS IZGYJ_ �I /� ✓�_� ('�- TYPE OF ROOF COVERING
CITY&ZIP ✓G / 992-78
�� ^' EXISTING
PHONE—M— `,!9a_ 7 8 C—� - BUILT-UP ROOF
LICENSE
NUMBER Y/77/7 ASPHALT SHINGLES ❑ 4,/
LICENSED
underCONTRACTORS DECLARATION
(commencing
effect
I hereby affirm that I em usinnes untler provleione of Chapter B IInwith Section WOOD SHADES
7000)of Division 0l the Business and Professions Code,and my license le In lull/ores and
License
WOOD SHINGLES ❑
Llcenae Cleee 31�L�_ Llc.Number
Det. Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that 1 em exempt from the Contractor's 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,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
o the Contractor's License Law(Chapter 8(commencing with Section 7000)of Division 3 of the , l
Buslnees end Profeaslons Cotle)or that he la exempt therefrom end the basis for the allapetl ASPHALT SHINGLES 1SW�
exemption,Any vlolatlon of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dollars($500).): WOOD SHADES
❑I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure la not Intended or offered for sale(Sec.7044,Business and Profes.
alone Code:The Contractors License Lew does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such improvements are not Intended or offered for sale.If,however,the building or improvement
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,em"elusivey contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who build$or Improves thereon,and who contracts for such project.
with a contractor($)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
C]I am exempt under Sec. ,B&P.C.for this reason
Owner Date AP I j'jl DATE VALUATION PE MIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to soil-insure for Workers compenaatlon, Ullding
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this oV 12 � CZ, A
p rmit Is Issued. /� Ir[O U [�
I have and will maintain Workers Compensation Insurance,as required by Section 3700 Xl /q,' Seismic
the Leber Code,for the performance of the work for which this permit Is Issued.My Worker's VI'" Ll/rC(.��II+,�/ "s n Total
Compensation Insurance carrier and II n mbar are: 11 'Q
Carrier_X. M J/1 PJA. /Qi Policy No. 0I JD7e90 PERMITA AOT RIZAT DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' 7
COMPENSATION INSURANCE N.C.
(This section need not be completed If the permit is for one hundred dollars($100)or less.) 0
I certify that In the performance of the work for wtqch this permit Is Issued,I shall not employ
-any person In any manner$o as to become su jea the W o peneafion Law.of call- All roofs s all a inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date IN;L_57 Applicant 1,4 tip inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: II,after mak at Certlficete of Exemption,you should become Applicant understands and will comply with all non point
subject to Ne Workers'Compensation provisions of the labor Cotle,you must forthwith comply PP P Y
with such provisions or this permit shall be deemed revoked. source re lations.
I certify that I have read this application and state that the above Information le correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,antl Allr Of VBring lass�C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
ap(we) purposes. P-�a_7Z 7
(We)sprees save,P.n ..indemnify
and keep harmless the City of Cupertino egelnat Ilebllltlee,
judgments,Coate and expenses which may In any way accrue against said City coneequenca
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