R 5072 PERMIT R_ 5012
APPLICATION FOR CITY OF CUPERTINO NUMBER
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
ME:KS d 6i 90 RESIDENTIAL 11._� COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
VES ❑ If yes—I understand that a Class A
NAME ^ r / �y p✓ r/ .[,1 NO roof assembly is required.
Iniial I.C.B.O.H
ADDRESS / EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS 02
CONTRACTOR'S
r TO BE REMOVED TO BE RETAINED
NAME ��°A S G°ovsr,Ivarv... 8—I✓mia/�I.YC
ADDRESS0 CiJ� C 4fo Y �f' S'b--o TYPE OF ROOF COVERING
CITY 8 ZIP � �/
EXISTING
PHONE 7yr-S".? Yo BUILT-UP ROOF ❑
LICENSE
NUMBER .f7SS' — ASPHALT SHINGLES
LIC SED CONTRACTORS DECLARATION 7/L/
I hereby affirm that em stl under provisions of Chapter B(commencing withSection WOAD SHAKES
7000)of Division 3 0l the Business and Professions Code,and mySlcense is In full force and
affect, np WOOD SHINGLES 5�X
License Class O Llc.Number — J 75 5S
Data y8'/f-24C Contractor ape Y C A,5-% OTHER(SPECIFY) ❑�
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am 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 .❑ .
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractoee License Law(Chapter g(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 ❑
exemption.Any violation 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).):
01,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 sale(Sec.7044,Business and Profes.
Bions Code:The Contractor's License Law 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 ❑ fpr*A,4_0
such Improvements are not Intended or offered for sale.If,however,the building or Improvement STC! p
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,am exclusivey contracting with licensed contractors to construct
the project(See. 044,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
wlth a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 6 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under Penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, b BUIIdl
f ae provided for by Section 3700 of the Labor Code,for the performance of the work for which this /� �a
permit Is leeuetl. r,x,� �C ���6 ��% $elSfrllCJ_
❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 of �I J f r)
the Labor Cotle,for the performance of the work for which this permit is Issued,My Workers
Compensation Insurance carrier and Policy number are: Total
t
Carrier-�00 4 ✓ M/r�(� Policy No/61&eA_3.7/37/-o/C if yr 'PERMIT AUTHORIZATIO DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.Q
(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 emJoy
any person In any manner so as to become subject to the Workers'Compensation Laws of Lull. All roofs shall bb inspected prior t any rodVing material being
fornia. installed. If a roof is installed without first obtaining an
Date _ /S�'9G Applicant &t 64-Ve 's Eo.vsT, inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: 11,after making this Certificate of Exemption,you should become Applicant understands and will
subject to the Workers'Compensation provisions of the Labor Coda,you must forthwith comply PP comply P y with all non point
t
with such provisions or this permit shell be deemed revoked. Source regulations.
1 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-mention ad property for In.
aP purposes.
WO)
(We)agree 10 save,Indemnify and keep harmless the City of Cupertino against liabilities,
jutl mons,costs and expenses which may In any way accrue against said City In consequence
of tRa 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICF Onpv