R 5758 (2) PERMIT R_ 5758
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APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (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 ,ry/
t O L 1' I Q ' v �/ l�� `J ^ RESIDENTIA COMMERCIAL OTHER
OWN I understand
FIRE AREA
YES ❑ Ii oe
NAME h-e — ntlerefantl that a Class A
(' roof assembly is required
• , r ^ NO Initial I.C.B.O.$
ADDRESS—1 7 `�" C, f e"1 U I el J rZ EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS Jr
CONTR ZOORRSS� C
NAME'. I 1U`e `'--'� Q G G `r�Q
%. TO BE REMOVED Y TO BE RETAINED
ADDRESSS TYPE OF ROOF COVERING
CITY 8 ZIP t��fL;> EXISTING I
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER (�� - ASPHALT SHINGLES n
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am Ilcensed under provisions of Chapter a(commencing w h ac WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my Ilconee le In ful rce e
effect.. OD SHINGLES ❑
License Claes Lid.Number
Date �If_4? S Contractor N( I WOOD
(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's 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 Elapplicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Lew(Chapter 8(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he is exempt tharefrom 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($500).):
❑I,as Owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles-
' alone Code:The Contractors License Lew does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for self.If,however,the building or Improvement 1
Is Bold within one year of completion,the owner-builder will have the burden of proving that he did OTHER (SPECIFY)
not bui
ldor Improve for purpose of sale.). oG � QK
I]1,as owner Of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professin Code:The Contractor's License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
E]I em exempt under Sec. ,B&P.C.for this reason
Owner
WORKER'S COMPENSATION DECLARATION APPLICATION DATEI VALUATION PERMIT FEE
I hereby affirm under penalty of pedury one of the following declaration:
❑f have and will maintain a of the cab of Conant to epeeInsure for Worker's Compensation, ay �4 0 BUlldlrl$t ,
as promit Is is for by Section 3700 01 the Labor Code,for the performance of the work for which this Il � �`/[��_j��F_�7�-N/`-•F(—iYt
permit le lveued. Selsml
1 have and will the
performance
Workers Compensation Insurance,hthis as required by d.Section 3700 s � s` //-
abor Code,for the performance of the work for which this permit Is Issued.My Worker's - ,v� I �y1_ N� Total
CompeCnsetlon+Ine�urs.sn.ca carr.ie.[r)end Pollq number are: 17 It /
Carrier J I`'�1 1 - T"h� Pog-11I1 z y &t�-R� P R�Jv11PklU HORIZAT ON DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit is for one hundred dollars($100)or lase.)
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 Can- All roofs shall be Inspected prior to any mill mi nal being
fornia. I installed. If a roof is installed without first obtaining an
//� 1
Dale `� ' ' Applicant [ inspection,I agree to remove all new materials for inspection.
NOTICE a APPLICANT,ompe atter making provis This f the
Of oExemption,, ou mustforthwith lbecome
comply Applicant understands and will comply with all non point
with such
h ro Workers'Compensation she be deem d the kebor Code,
with each pmat I he or this permit shell n deemed revoked sOUTCe regUIa110RS,
1 coNet leve reed this application and elate that the above Information tobuilding
Is correct. agree
to comply byauthorize
all city and county of this
sits and stele laws relating to building conetr erty f and ��lIT6Qf coverings to be class°(i"Or better. pyo
hereby eulhodze representatives of Ihla city to enter upon iheabove-menllonetl property for In. ,1111 J\/1 6 Q
spectlon purposes. ,I .-
(We)agree to save,Indemnity and keep harmless the City at Cupertino against liabilities,
judgments.costs and expenses which may In any way accrue against said City In consequence
of me 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY