R 5253 (2) PERMIT
APPLICATION FOR CIN of cuPERTINo
NUMBER R- 5253
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAYS PERMIT ISSUANCE OR
WITH
DAVES FROM LAST CALLED INSPECTION.
BUILDING ADDRESS (� ^J/
V1 a —1 Lo I O y/ r_1 v� _RESIDENTIAL COMMERCIAL OTHER
OWNER'S a /� t/ .JIB' y^/ I HAZARDOUS FIRE AREA
�o h n �4- r L c6q g_o Rai ai r L„i_'p YES ❑ If yes-I understand that a Class A
• NAME roof assembly is required.
NO ❑
Initial E
I.C.B.O.
ADDRESSaa 51 Lo Txu �=Iyo T
PHONE 0� ' N
Q _J NUMBER OF EXISTING COV RINGS
CONTRACTOR' /� � ^y/y /� - '
NAME �1.L.-I I c�P00,'i nG TO BE REMOVED TO BE RETAINED
ADDRESS ., /� .
- TYPE OF ROOF COVERING
CITY&ZIP (3(D EXISTING
PHONE i `46
BUILT-UP ROOF ❑
LICENSE
NUMBER •p ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code.and my license Is In full force and
effect. q
WOOD SHINGLES ❑
License CIa= r_ Lie.Numbe
Date Contractor OTHER(SPECIFY)
OWNER the LDER DECLARATION PROPOSED
hereby affirm that l am exempt from the e: Any
License Lew for the requires
naso
(Sec.7031.5,Business and Professions Cade: Any city or county which requires requires permit to
consimct,or su Improve,damelish,a si n d sta eny mentructure,that he Is licenseor to issuance,to therovisi the BUILT-UP ROOF
applicant for each permit a file a signed r 9(commencing
Inst g with
Sectio pursuant to the provisions the
^� of the Contractor's License Lew(Chapter 0(commencing whh Sactlon 7000)of Division 3 0l 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)J:
❑l,as owner of the property,or my employees with wages as their sole compensatlon,will do WOOD SHAKES
the work,and the structure Is not Intended or olferod for sale(Sec.7044,Business and Profes.
sions Code: The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
improves o anent and who does such work himself or Through his own employees,provided that r 1�
such Improvements are not Intended or work
himself
for fele.IL however,the buildingmploye or Improvement A V
Is sold wlthln one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY)
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 does not PROVIDE I.C.B.O.REPORT NO. 5�`t(
09
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 Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt untler Sec. ,B&P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: as�.ra•.s,s
❑I have and will maintain a Certificate of Consent to selbinsur°lot Workers Compensation, �yq Building I W
es provl for by Sactlon 3]00 of the Labor Code,for the performance of the work for which this I I� I I�I (Y_^ f'm
per
Is ad. Seismic 1
have antl will maintain Worker's compensatlon Insurance,as required Is by Section 3700's z-�9f)
iha bar Code,for the performance of thew k for wNch This permit is Issued.My Worker's
Compete I au �ie nd Ilc n snare: I1(Jr���(/-�-/7-(/./y�/� Total s
Carrier Policy No.L1v��_4i PERMIT AUTH RV4TION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thio section need not be completed If the permit Is for one hundred dollars($100)100)or less.)
I certify that In the performance of the work for which this permit is Issued,I shall not em lay
any person in any manner so as to becom object to the Works ompensalion Laws of&H. All roof t shall be inspected prior to any roofing material being
f°`nia. installs d. If a roof is installed without first obtaining an
Date t As I inspect) i,I agree to remove all new materials for inspection.
IN ICE TO APPLICANT: If,alter making this Certlfcat of Exemption,yo should become
subject to the Workers'Compensation provlBlons of the or Code,you must forthwith comply 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 If correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,antl Al roof coverir eclass"C°Or better.
hereby authorize representatives of this city to enter upon the above-mentlonetl property for In- l '
Boeotian purposes. /'y
(We)agree to save,Indemnify and keep harmless the City of Cupenino against liabilities, (�1
judgments.costs and expenses which may in any way accrue against said City In consequence
of the granting of this permit. SIGNATURF 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 BERROVIDED FOR INSPECTION
OFFICE COPY