R 5249 (2) PERMIT R_ . 5249
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
F I
W
• THIN 180 DAYS OPERMIT ISSUANCE OR
WLAST DANS FROM CALLED INSPECTION.
BUILDING ADDRESS r� ,p y- /
Opt/_3 �1 76Pf f-� 44,di� RESIDENTIAL.,COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class A
NAME roof assembly is required.
NO ❑ Initial I.C.B.O.11
ADDRESS EXISTING ROOF COVERING
PHONE .
NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
F -? &CF,1 � C � ��AQ7- TO BE REMOVED TO BE RETAINED
NAME I _ / V [�' / -
ADDRESS /D7� : ��oeA N/SJ_� APIC— TYPE OF ROOF COVERING
CITY 8 ZIP EXISTING
PHONE d2 ? :;2 2� BUILT-UP ROOF ❑
LICENSE
NUMBER S3 3 c_Jl09 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION \
hereby affirm that I am Business
under Professions
lone of Chapter g(commencing with Section WOOD SHAKES
]000)of Olvlelon 3 0l the Buelneae entl Prolesslons Code,and my license Is In lull force and
effect. /� fF� /— WOOD SHINGLES ❑
License Claes /1-k- - ?/-q Lie.Number s
Date
_ rj� m6 Contractor O OTHER(SPECIFY) ❑
OWNER-BUILD CLARATIO PROPOSED
I hereby affirm that I am exempt from the ractor'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 ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
• of the Contractor's License Law(Chapter B(commencinp with Section 7000)of Division 3 of the (I 11ii55��
Business and Professions Code)or that he Is exempt tlleralrom 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
e civil penalty of not more than five hundred dollars($500).):
01,as owner of the property,or my employees with wages as lhalr sole compensation.will do WOOD SHAKES ❑��®� 0�
the work,and the structure Is not intended or offered for solo(Sec.7044,Business and Profes-
sionsCode:The Contractors License Lew does not apply to an owner of property who builds or ISO
WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees, rovided that El
such Improvements are not Intended or offered tot sale.If,however,the building or Pmprovement IY ur wi-EH HNO
Is sold within 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.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors 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(a)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
El am exempt under Sec. ,B B P.C.for this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: /`
E]I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, Building 6
)' as provided for by Section 3700 of the Labor Code,for the performance of the work for which this p. O
permit Ie Issued. I1//p/q(o 5/ Seismic
i4f 1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of l
_the Tabor Code,for the performance of the work for which this permit Is issued.My Workers O
Compensation Insurance carrier and Policy number are: Total /D
Carrier S'7' D Pj / n Policy No19• PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(Thio section need not be completed If the permit Is for one hundred dollars($100)or IasaJ
1 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'Compensalion Laws of Cell- All roofs shA be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will core
subject to the Workers'Compensation previsions of the Labor Code,you must forthwith comply PP ply with all non point
with such provisions or this permit shelf;be deemed revoked. SOOlCe reg1118110NS.
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 state laws relating to building construction,and All roof coverings a Class°C°Or b tter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)spree to save,expenses
and keep harmless the City of Cupertino Ci y It consequence liabilities,
• of the gran coats and permit. a which may In any way accrue epelnsl ealtl City n consequence
of the granting of this permu. NATURECANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE NSRDATE 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 COPV