R 5995 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R5.995 .-
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 (boy qq L 1
/Oso I '` w v ( �� 74-V RESIDENTIAL—ZCOMMERCIAL OTHER
OWNERS / C HAZARDOUS FIRE AREA
NAME (—•�r r J•� YES ❑ If yes—I understand that a Class A
hoof assembly Is required.
1 NO ❑ Initial I.C.B.O.g
ADDRESS J-/if f-y Ifo e f.J V/ EXISTING ROOF COVERING
PHONE . f'6 O S Z NUMBER OF EXISTING COVERINGS- /
CONTRACTOR'S /-� ,fir L— r
NAME //Y—YI " ' ° ':Y P ,1f� �FD(`t U") TO BE REMOVED TO BE RETAINED
TYPE OF RQOU
CITVADDRBZP �u ESS
I Ll.7l�4-���e./�- 219
EXISTING
- PHONE. / BUILT-UP ROOF - ❑ ��Q
LICENSE
NUMBER ASPHALTSHINGLES El �
! '
LICENSED CONTRACTORS DECLARATION
I hereby affirm
3 that I am licensed under provlelons of Chapter B(commencing with Section WOOD SHAKES A
7000)of Division of the Business and Professions Code,and my license is In full force and
effect.
�•��� O
License Class_ Lic,Number WOOD SHINGLES El
Date 7�1Contracor MY kle&t AUJ OTHER(SPECIFY) JUL IIIl
OWNER-BUILDER DECLARATION PROPOSED !• v �'l
I hereby affirm that I em exempt from the Contractor's License Lew for the following reason. CII 1 Uf LUrtH I INO
(Sec.7031.5,Business and Profession 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 ❑
of the Co for such permit to IIIe a signed r 9(co em mel he Is licensedSection
pursuant to the provisions the /
of the Contractor's License Lew(Chapter 0(commencing with Section 7000)of toDivision 3 gl the El
Business and Professions Code)or that he to 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(8500).): WOOD SHAKES
❑I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes. -
sionsCode: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
such Improvements are not Intended or offered for sale.If,however,the building or improvement
Is sold within one year of completion,the owner-builder will have the bumen of proving that he did OTHER(SPECIFY) ❑
not bull mprove for purpose of sale.).
as owner of the property,am exclusively contracting with licensed contractors to construct
ih roject(Sec.7044,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
with a contractors)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
L]I e xe t under c. ,8&P.C.for this reason
Ow j
WQ ER'S COMPENSATION DECLARATION �P APPLICATION DATE VALUATION PERMIT FEE
I hem affirm under penalty of perjury one of the following declaration:
❑1 havevided and Sectiill on
tain a3700 Certifiof
of Consent theperforma for Workers Compensation,which
///��� Building as provided for by Section 3]00 of the Labor Code,for the performance of the work for which this D c GGGOx
permit la Issued.and SeIBmIC
❑ have and will maithe performance
Worker's Compensation the work
for Insurance,as required Is I by Section 3700's
_the Lebon Code.for the performance of the work for which this permit la Issued,My Worker's Total
Compensation Insurance carrier and Policy number are:
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 w— ��
(This section need not be completed it the permit Is for one hundred dollars S1 00)or lase.)
1 certify that In the performance of the work for which this permit is Issued,I shall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell. All r00(S11 inspected prior to any roofing material being
fornia, installed. If a roof is installed without first obtaining an
Data (Z/S� Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: 11,alter making t Cartllic t Exemption,you should become
subject to the Workers'Compensation pro n of the Le or Cotle,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shalCbe deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information to correct.)agree
to comply with all city and county ordinances and elate laws relating to building construction,and All ro coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
IWe)agree to save.Indemnify end keep harmless the COY of Cupertino against Ilebllltlea,
judgments,mets and expenses which may In any way accrue against said City In cone........
of the granting of this permit. SI URE Or A LICANT ATE
PRE-INSPECTION: PLYWOOD: -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