R 5463 APPLICATION FOR CITY OF CUPERTINO
Nu s'RR- 5463
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
II(o6 Sc&1an6'DTZ• / PXZi 1710 IT
RESIDENTIAL_9i COMMERCIAL OTHER—
OWNER'S
THER
OWNER��'yyS���� n,t^'^,, HAZARDOUS FIRE AREA
NAMEI?ktPilrla� -FYLIV) + Mtabe1 VES ❑ If is eq iced.hat ClassA
�- NO My is required.
/�r� Q ❑ Intltal LCB.O.q
ADDRESS 1IIOW 3c)f1CJnd-D - - 63 peleano95W EXISTING ROOF COVERING
PHONE 402 I5e2_ NUMBER OF EXISTING COVERINGS
CONTRACTOR'S Nn � TO BE RETAINED
NAME A 11 ���(;MS �.lA^ TO BE REMOVED) A G
ADDRESS �7�/�,,;'� �— TYPE OF ROOF COVERING
CITY&ZIP �-+��1`� hI/+ �� Jn•�,.r�fJ ���- I (EXISTING .
PHONE a•— BUILT-UP ROOF ❑
LICENSE
NUMBER 5)O=CI ) )� �}, ASPHALT SHINGLES ❑ -
LICENSED CONrrRACTrORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES 'YrpVl`
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
affect WOOD SHINGLES
Date ❑
License Class Llc.Number -LI �•-�
I O Contractor11$ ii In OTHER(SPECIFY) ❑
Data
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractors License Lew 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 ❑ �1� J
applicant for such permit to file a signed statement that he la licensed pursuant to the provisions V /
of the Contractor's License Law(Chapter 8(commencing with Section 7000)of M71ilarr5vf /q
• ex elnpse and Any violation of Code)or that he le exempt Therefrom and the subject
the aIle (�SP SHINGLES T
exemption.lty of violation more
el than
fon hundred
by any s($5 ani fora permit subject ppllc t u
e civil penalty of not mora than live huntlretl tlollers($500)J:
[D 1,as owner of the property,or my employees with wages as their sole com lion,will do WO HAKES
the work,and the structure Is not Intended or offered for sale(Sec.7044,Bust a analone Cade:The Contractor's'License Lew does not apply to an owner of prop 'who OCTOC br O 19 HINGLES
improves thereon,and who does such work himealf or through his own employ ,provided that ❑
such Improvements are not intended or offered for sale.If,however,the buildin r Improvement
Is sold within one year of completion,the owner-builder will have the burden of oving that he did OTH SPECIFY) ❑
not build or Improve for purpose of sale.). R„ ,
❑l,as owner of the property,am exclusively contracting with licensed cant 61%71
the project(See.7044,Buslness and Professions Code:The Contractors License aw E 1.C.B.O. REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such Projects
with a contractor(a)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B A P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
O
I hereby affirm under penalty of perjury one of the following declaration:
C]I have end will maintain a Certificate of Consent t°self-Insure for Workers Compensation, I Building n 2 7
as provided for by Section 3700 of the Labor Cade,for the performance of the work for which this
y O
P rm is lsauetl. Seismic OV
- have antl will maithe pert Worker's Compensation the workfor Insurance,as required Is
by Section Worker's's Il 1
C Labor Code,for the performance of the work for which this permit la Issued.My Worker's CJ / 7r O
Compen n Insurance carrier and Policy number ate:�,y Total
Carrier Ii1G!O- ) n1 CyNp. )a$ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit Is for one hundred dollars($100)or IeesJ
I certify that in the performance of the work for which this permit ie Issued,I shell not emotoy
any person In any manner so as to become subject to the Workers'Compensation Laws of Cah- All roofs shall be inspected prior to any roofing material being
°`nl°' installed. If a roof is installed without first obtaining an
Oats Applicant 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 comply subject to the Worker°'Compensation provisions of the Labor Code,you must forthwith comply pP ply with all non point
with such provisions or this permit ahalObe deemed revoked. source regulations.
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 roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mendoned property for In.
apache'purposes.
(We)agree
t°save,Indemnity and keep harmless the City of Cupertino against liabilities, J ! /
jutlgments.costs antl expenses which may in any way accrue against mid City In consequence
of the fir
Ott
permit. SI_a_UROF APPL9ANT 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