R 5765 (2) PERMIT R_ 5765
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 / AL// `
4JJl 0 RESIDENTIAL - COMMERCIAL OTHER
OWNER'S // HAZARDOUS FIRE AREA
C /� L T T VES El If yes-I understand that a Class A
NAME roof Sasembty is required,
NO ❑ Initial I.C.B.O.#
ADDRESS n's K4--XI L EXISTING ROOF COVERING
PHONE } 3 — U U NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S y�
NAME /I-IV r�l40 NSI R/O b/�' �L Z G�, ' TO BE REMOVED _TO BE RETAINED
ADDRESS �i\ 8b IC 2y(O r0[J �. J. / S'�/ S-' TYPE OF ROOF E
CITY&ZIP II.JJ EXISTING
PHONE 405 ' (4 BUILT-UP ROOF /vim �i lD
LICENSE, ✓1
NUMBER SASPHALT SHINGLES
❑�J
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Olvlelon 3 of the Business and Professions Code,and my license 16 In lull force antl
ental. C_� / WOOD SHINGLES ❑
License Class- LIC.Number /6/S3 -
Date 9 -10-574y Contractor , -/ 7L0--`— OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law 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 provialons
of the Contractor's License Law(Chapter p(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 ❑
nmplan.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
civil penalty of not more than five hundred dollars($500).): 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 Pro ,f
slopns Code:The Contractors License Lew does not apply to an owner of property who bull or IHER
OD�HIN MU A7 f L=2Im roves thereon,and who does such work himself or through his own employees,pravitl e ❑such Improvements are not Intended of offeretl for sale.If,however,the building or Improve � / TIs told within one year of completion,the owner-builder will have the burden of proving thelh �d (SPL�I(rz-f /notbuild or Improve for purpose of eels.). p❑Lesowner Sac.70th,property,amaxclusivelyfessio sCode:The ontrasorsLic nseLto cons 6VJ ( 8CREPORT NO.' ` �" g-
the project(Sec.7044,Business end Proeselona Code:The th lice sed LicenseLctorsew doe tapply to an owner of property who bullds or improves thereon,antl who contracts for such proj awith a contactorfs)Ilcensetl pursuant to the Contractor's License Lew. OVIDE M INSTALLATION SPECS.
❑1 am exempt under Sec. ,B s P.C.for this her
Owner Date Y_
VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: ♦i/-y
❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation,LaBuilding /(/�/
as provided for by Section 3700 of the"bar Cotle,for the performance of the work for which this
per t Issued.
have and will maintain Worker's Compensation Insurance,as required by Section 3700 of /�/�//\\ of Seismic
-ih or Code,for the performance of the work for which this permit is Issued,My Worker's /V/ GQV Total
/Y
Compensation Insurance carrier and PoflWa�y\umber are: /-, /
Carrie,S7'4TC" 1—UAJI Policy Nowt 06 U2 -'r7/ PERMITAUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I] ' ^
(Thio section need not be completed If the permit Is for one hundred dollars($100)or less.) SVL`/
�o/
I certify that In the performance of the work for which this permit Is IssueQ shell not employ
any person In any manner so as to became subject to the Workers'Compensation Laws of call- All roofs shall be inspected prior to any roofing material being
forms, installed. If a roof is installed without first obtaining an
Oats Applicant inspection,I agree to remove all new materials for inspection.
subje�toEth WoP ers'Oo Com ,after pensation n provisionis ofathe11cate of Laborr Code,Exemption,
mustforthwithlbcomply Applicant understands and will comply with all non point
with such provisions or this permit shalgbe deemed revoked, source regulations.
I certify that I have read 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,and All roof c verings to be Is r better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In. I/ -
epection purposes.
(We)agree to,eve,Indemnify and keep harmless the City ai Cupertino y inagainstcon liabilities, P
odgmsnta,coats and expanses which may in any way accrue against said City in consequence NATURE OF APPLICANT
- of the grenling of thio permit. DATE
. PRE-INSPECTION: PLYWOOD: - IN-PROGRESS: A
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
OFFICE COPY