R-5374 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5374 .
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
Ill 2D #_ mw.n l I RESIDENTIl COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAMESi Amr�k SAn VES ❑ roof assembly
isrequired. Class
root assembly isand that
q NO ❑ Initial I.C.B.O.It
ADDRESS 3 1 9 5 �eC i t LV) EXISTING ROOF COVERING
PHON O y31- °1388 NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S yn/M
NAME .JCai a(gop.o. TO BE REMOVED `t TO BE RETAINED
ADDRESS / ...�� /\fits ./1_. I C S p�I TYPE OF ROOF COVERING
CITV 8 Z(,IP l0�^-�` ^� ��t1 W J / EXISTING
PHONE&O!� / 1 -n 11� BUILT-UP ROOF El
LICENSE OZ L v ASPHALT SHINGLES ❑
NUMBER
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license lain full force and
effect. 13 �` WOOD SHINGLES El
License Clas _q 1 C ZD Lic.Number yy�
Dets�d_I&' r contractor 5 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,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
of the Contractor's License Law(Chapter 9(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
• exemK
ption.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).): WOOD SHAKES❑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.
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES El
thereon,end 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) E]not build or improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed 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.
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a comractor(e)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B 8 P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPL•IC TION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: '+ /
F7 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, C' BUllc!14
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
rillpermit Is issued.
rI
�/r Seismic
❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 0l n
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's��r
Compensation Insurance carrier and Policy ii are: �{ (Jf Total
Carne&fllbI I'L � Pp;;py No,357-1 ib ) PER 7-AUTHORIZATION DATE
CERTIFICATE OF EXEMPTI N FROM WORKERS' s/r
COMPENSATION INSURANCE RANCE N.O❑
(This section need not be completed if the permit is far ono hund do a($100)or lass.)
I certify that In the performance of the work for which this parml Is issu ,I shall no employ
any person in any manner so as to become ct to the Workers' nsatipn Law pi call- All roofs shall be inspected prior to any roofing material being
installed. If a roof is installed without first obtaining an
Datep, G� Applica inspection,I agree to remove all new materials for inspection.
subject CE TO
ow rrkersCOom ensiion proivisionis Certificate of s of the Labor Code,yolu must forthwith le Applicant understands and will comply with all non point
P P Y PY
with such provisions or this permit shell be deemed revoked. fCe regulation5AP
I certify that I have read 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 All of covering lass"C"or better.
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, �IIJI J
judgments,costa and expenses which may In any way accrue against said Olt y In consequence
of the granting of this permit. SIGNATURE OFANT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY