R 5201 (2) PERMIT R_ 5201
APPLICATION FOR CITY OF CUPERTINO NUMBER
R-
PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(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
T1
13 ' G1�tYj_G l_ /-, r. PL RESIDENTIAL__)_< COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
VES ❑ If yes-I understand that a Class A
NAME p,O Q t? r IM L.L ' /P roof assembly is required.
/ 7— NO f Initial I.C.B.O.#
ADDRESS .2 1 4 ) 3 vp'�r'r'a- C. EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S //� //r
C.O I f1 7-1 Y1.G TO BE REMOVED �- TO BE RETAINED
NAME
ADDRESS ' / (y TYPE OF ROOF COVERING
CITY&ZIP C:_ Ir.
q �1 EXISTING
PHONE - oZ -7 — L / BUILT-UP ROOF ❑
LICENSE
NUMBER _ ASPHALT SHINGLES ❑
LICENSED CONTRAC SDECLARATION
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. (� 9 WOOD SHINGLES ElLicanae Class `-�- • Lic.Number t D
Date-�O-4I—`T(a Contractor / S - flti2 OTHER(SPECIFY) ❑
OWNER.BUILDER DECORATION 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,orrepalr any structure,prior to Its Issuance,alsorequireslhe BUILT-UP ROOF --- ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions .^y
of the Contractor's License Law(Chapter g(commencing with Section 7000)of Division 3 of the
• Business end Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES E]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($500).):
mos owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ED
at work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles
Bions Code: The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES E]Improve$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 burden of proving that he did OTHER(SPECIFY) r
not build or improve for purpose of sale.).
El 1.as owner of the property,am exclusively contracting with licensed contractors to construct x`
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who builds or Improve$thereon,and who contracts for such projects
with a contractor($)licensed pursuant to the Contractors License Law, PROVIDE MFG,R.INSTALLATION SPECS.
C]I am exempt under Sec. ,B 8 P.C.for this reason
O /a g�I�r�Ac o APPLICA'AO DATE VALUATION PERMIT FEE
WORKE COMPENRB SATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: ® ^J�
ave and will maintain a Certificate of Consent to self-insure for Workers Compensation, 7� BUIIdm� I 1
a$ rovided for by Section 3700 o1 the Labor Code,for the performance of the work for which this O
permit Is Issued, C I ¢?
SGl.have and will maintain Workers Compensation Insurance,as required by Section 3700 of �/' y Seismic
the LLabor Code,for the performance of the work for which this permit Is Issued,My Workers "SYAIP ll `
-Compencsation Insurance carrier and Policy number are: `�/�'CC �7 �V Total
Carrier STC,TeC 1. Sh S Panay No. {4 V 7 7 la PERMILAUTHORIZATION DATE
CERTI ICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 �
(Thio section need not be completed If the permit Is for one hundred dollars($100)or IessJ
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any parson In any manner so as to become subject to the Workers'COmPen$ation Laws of Cali. All roots shall ITe 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.
come
subject
NOTICE
EtA Workeres'Compef.after nsation provisions ofrhoCertificate
of Exemption,
you must forthwou ith comply Applicant understands and will comply with all non point
with such provisions or this permit ahel�be deemed revoked. SOUfCe regulations.
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 slate laws relating to building construction,and All roof goverrigsto be class"C°Or better.
hereby authorize representatives of this city to anter upon the above-mentioned property for In-
spectlon purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities. {
Judgments.costa and expenses which may In any way accrue against said City In consequence
• of the granting of this permit.- SI ATURE OF APP I ANT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY -