R 5752 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5752
REROOF PERMIT INSPECTION DIVISION PERMIT EXP1RAT ON
(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
100060 5 AY,TTA ,e,Us A RESIDENTIAL COMMERCIAL OTHER
OWNER'S t HAZARDOUS FIRE AREA
NAME L qe-I — ) Q- S 1.A r i P I UJAM G YES ❑ If yeas understand is req that. Class A
W Z— IJ C7 roof assembly Is required.
d NO In#ial I.C.B.O.If
ADDRESS- s/�•n l 0_U PT• Q SO/ ? EXISTING ROOF COVERING
PHONE z S —' Z 3 NUMBER OF EXISTING COVERINGS -L
CONTRAS
TO BE REMOVED TO BE RETAINED
NAME p l��}(�S A�C -f ���j]�,
ADDRESSfC TYPE OF ROOF COVERING
CITY a ZIP 7-:-L92_ Lt.J CC1 uo --Ave- :S Q Z-
€Xl$S1Nf
PHONE Lion — Lt q g — 0491: � � BUILT-UP ROOF ❑
NIUMBER • vJ 3� x�l2es 331 q q ASPHALT SHINGLES ❑
LICENSEDdunderCONTRACTORS DECLARATION X L,4ye?
hereby affirm that em licensed under Professions
loss of Chapter 9(commencing with Section WOOD SHAKES /�,-
]000)of Division 3 0/the Business and Profesalone Code,and my license Is In lull lone and
effect.
W_
/ L WOOD SHINGLES
S5q
License Cleve v LIc.Numbery'�`s�3v
Date tS conirecror OTHER(SPECIFY)
OWNER-BUILDER DECLARATION � Y/
I hereby affirm that I am exempt from the Contractor's License' for the following reason. l4nmm
(Sec.7031.5,Business and Profesalone Code: Any city or uti y which requires a permit to �/
construct,altar,Improve,demolish,or repair any structure,. to Its Issuance,also requires the BUILT-UP ROOF ❑ d
applicant for such permit to lila a signed statement that he is licensed pursuant to the provisions at
of the Contractor's License Lew(Chapter 9(commencing with Section 7000)of Division 3 of the p,r
Business and Professions
Code)or that he le exempt therefrom end the Beale for the alleged ASPHALT SHINT"aLS� ❑
'-� exemPpen.Any lty of oft tion more
Sectionfve hand S by any s($5 0t):nt a Permit subjects the applicant to
e civil penalty of not mor°then five 031.5 tl dollen($500).): p�`�+r t f
01,as owner of the property,or my employees with wages as their eels compensation,will do WOOD SHA3U i, F11W1D ❑ CLA•SS A
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes. H'La /T
slots Code:The Contractors License Low does not apply to an owner of property who builds or WOOD SHINGLES LI(71 T rY
Improves thereon,and who does such work himself or through his own employees,provided that !, (k;,(I l fix ❑ N r/Le�,
such improvements are not Intended or offered for sale.If,however,the building or Improvement WI,1Y Ur V V
Is sold within one year of completion,the ownenbultier will have the burden of proving that he did OTHER (SPECIFY) l�r�CJ[. /LCA•
not build or improve for purpose of sale.). / ` —
❑I,esowner ofthe property,am exclusively contracting with licensed contractors to construct Z
the project(Sac.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 contractors)licensed pursuant to the Contractors License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,S 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: '2-1
•�
❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensetlon, Building 2.1 *r
as Provided for by Section 3700 of the Labor Code,for the performance of the work for which this o / g
p ma issuetl. /rq-B b 3 15 seismic 1 :7 O
have and will maintain Workers Compensation Insurance,as required by Section 3700 of
L bor Code,for the performance of the work for which this permit Is Issued.My Workers o
Compensation Insurance carrier and Poliicy�'number are: Total / a O
Carrier STA Q PoIIcyNo. 6-rA1-Q02-5"Zy PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the permit Is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit Is issued,I shall not employ I� J
any parson m any manner se as to become subject m me warkere'cempeneatmn Laws of cell. All roofs shall be inspected prior to any roe ing material being
°f"1°' installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTCE TOecome
subject lt.the Wor kers'Compelnsation proviPLICANT: I,after sionis ofethelLaborCoda, yotu mustufo thwlithshoudccomply Applicant understands and will comply with all non point
with such provisions or this permit shell be deemed revoked. Source rulations.
I certify that I have read this application and state that the above Information is correct. agree
to comply with all city and county ordinances and state laws retailing to building construction,and All rO CO Brings to
hereby authorize representatives of this city to enter upon the above-m°ntloned property for In. i
spection purposes.
(We)agree to cava,Indemnlly'and keep harmless the City of Cupertino against Ilabllltles,
judgment,costs and expanses which may In any way accrue against said City In consequence
of the granting of this permit. /Sly ATUR OFAPP ICANT DATE
PRE-INSPECTION: PLYWOOD: - - IN-PROGRESS:
INSP. DATE INSP. DAT INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL: /x
INSP. DATE INSP, DATE - INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY