R 5073 (2) APPLICATION FOR CITY OF CUPERTINO NUMB R R- 5073
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228- PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN IN DAYS OF PERMIT ISSUANCE OR
• 100 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS �7rc D �J
11061z- �
61 JI IZr � . RESIDENTIAL__X_COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
�n �n( C�r� YES [:I),,.roof
yes-IunderstandthataClanA
NAME 1 '�L. 1'-'J J G roof assembly is required.
FL,
NO Initial I.C.B.O.It
«.
ADDRESS g1 Z QSV 1 12-r—, I L, EXISTING ROOF COVERING
PHONE NUMBER OFEXISTING
1COVERINGS LAYE2,
CONTRACTOR'S /� J1/� TO BE RETAINED
NAME &6MISSAII-i �r'ING Co ., INC TO BE REMOVED
ADDRESS 229 2 LINCOLN Ali, . 951 A✓ TYPE OF ROOF COVERING
CITY&ZIP
PHONE EXISTING
(`��) � '" �q 1-� BUILT-UP ROOF ❑
LICENSE
NUMBER 1559 73a ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect. � WOOD SHINGLES ❑
License Class Lic.Number 5 *5 3
Date 900 Z�J�� Contractor R�aAt5SAf4Cfs QoDRI� OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the following reason,
(Sac.7031.5,Business and Professions Cotle: 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 1-100080 Law(Chapter a(commencln with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt Iherafrom 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).):
❑I,as owner of the property,or my employees with wages as their cote compensation,will do WOOD SHAKES ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profea.
alone 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 ❑ T
such Improvements are not Intended or offered for sate.It,however,the building or improvement L r 1 E I, r
Is sold within one year of completion,the owner-builder will have the fou men of rovingthat he did OTHER(SPECIFY) -r,
L.C.
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 floes not PROVIDE I.C.B.O.REPORT NO. �R
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 Lew, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
I
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration;
r ❑I have and will maintain 0 Certificate of Consent to sell-Insure for Worker's Compensation, -F �•
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this 00 Buildini
pa mit Is Issued. '1 $1342,7-5
it have and will maintain Workers Compensation Insurance.as required by Section 3700 of �V6 281996 Seismic I O
the Labor Code,for the performance of the work for which this permit Is Issued,My Worker's Total
-the
�I.ns�uraxnccee carrler/end P/o�licy number are: 4 J
Carrier �.I„VC�—ru'-h Policy No. 2"� ��� ILII PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(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 shell not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of Cell. All roots Shall be inspected prior to any roofing material being
fornia, installed. If a roof is installed without first obtaining an
Date 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 with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P y p
with such provisions or this permit shalgbe deemed revoked, Source regulations.
I certify that I have road this application and state that the above Information Is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction,antl All ro f coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentlonetl property for Ira /Z/'/'-
apache)purposes. a • /, �� /l�'�e'7 O L�77 illJ
(We)agree tocosts in onts, save,and indemnify w end keep harmless the City of Cupertino against liabilities,
olthe granting al Ihla permit. SIGNATURE
which may In any way accrue against said City In_
I
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
_i OFFICE COPY