R 5092 (2) PERMIT R_ 5092
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
RESIDENTIAL COMMERCIAL OTHER
HAZARDOUS FIRE AREA
AME 710 N/71 YES ❑ 11
s—I unl stand that a Class
y required.
rt� n NO Initial LC.B.O.ff
DRESS-IOS92 LSGt4 yilL�t ��9GK EXISTING ROOF COVERING
PHONE i^ P161
NUMBER OF EXISTING COVERINGS
CONT OR'Or��r _ tt
(lam_i�T'r- 1/ TO BE REMOVED TO BE RETAINED
NAME ^y ry
ADDRESS l I / 1 H—p C
CITY&ZIP
�y p EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE Q
NUMBER C Y 3 ASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am fleensed under provisions of Chapter 8(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and X e /
effect. (/n �ZZ
WOOD SHINGLES El ! //
Ucane lain Lie.Number v ��
Dale Contractor
W g� OTHER (SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby allirm that I am exempt from the Contractor's License Law for the following reason.
(Bac.7031.5,Business and Professions Code: Arty city or county which requires a permit to
conatruc6 alter,improve.demolish,or repair any structure,prior to Its Issuance,aeeorequireethe BUILT-UP ROOF ❑
applicant for such permit to flee a signed statement that he Is licensed pursuant to the provisions
of the Contractor's 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
a civil penalty of not more than five hundred dollars($500).):
E]1,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 Proles.
alone Code: The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES 1�.is"t`-X W p�"'I
Improves o thereon,ands are
who does ed work offend for sal ,rough If,however,
own employees, rovitle meet ❑' , ` 1
such I within one year
ere not Intended the
offered for leer.ill however,Thr en building or Pg that he did '—T�1 mss`p^p a
notIs ld bull or
prove aropurposetof s the Owner-bullderwlll have the burden of proving foal he oltl OTHER(SPECIFY) p�
not build lir Improve for purpose of eeleJ. .q�
I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Coda:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improve&thereon,and who coolness for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
E3 am exempt untler Sec. ,B&P.C.for this reason
Owner oats
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
1 hereby affirm under penalty of perjury one of the following declaration:
C]I have and will maintain a Certificate of Consent to calf-Insure for Worker's Compensation, �� - Building`-�
as provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this
permit Is Issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of '/ Seismic �_t a
the Labor Code,for th pa0 I'mance of the work for which this permit is Issued.My Worker's AUG{3 !v 1 Q/��s
Comp n�aetlon sumo eerrier and Polley number are: 996 1 1 J Total
lir - Poncy��3"'9S�6a0ro "' PERMITAUTHORIZA ION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.O.I]
(Thee 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 Sip
any person In any manner so as to become subN to the Workers'Compensation Lew.of Can- All roofs shaTI be inspected prior to any roofing indlerilWeing
himl installed. If a roof is installed without first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
NOTICE subject to the Worker
s'C mpensatio making
ovisiones of eh ff at or Code,youmust forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shall be 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 erste laws relating to building construction,and 11,Gr,O"ATUG
ot coverings to be class"O"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In. �t
spectlon purposes.
(We)agree . save,pensesIndemnify and keep harmless the Cly of Cupertino against liabilities
)utlgmenta,coats antl expenses which may In any way accrue against said Clty4n consequence
onRegrannngpuhiepermit. EOFAPPLICANT 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