R-5029 (2) APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R" 5029
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• -
BUILDING180 DAYS FROM LAST CALLED INSPECTION.
ADDRESS �
/053 1 US PLQ�.C�� RESIDENTIAL COMMERCIAL OTHER
OWNERS HAZARDOUS
HAZARDOUS FIRE AREA
/- ' ./ /_ ,�J..S.� VES ❑ If yes s I assembly
i req that. Clan A
NAME r//���"ms'µ-'�/L✓/ V/ I�� roof auI nbly is required.
NO ❑ Initial I.C.B.O.11
ADDRESS /03-3 ' /�_ �,Q-ac-C_Q___ EXISTING ROOF COVERING
• PHONE l Oa �ll���• NUMBER OF EXISTING COVERINGS �� `'^`✓"^^'1
CONTRACTOR'S
,�
NAME A14 � S Gn-$ jN TO BE REMOVED TO BE RETAINED
ADDRESS2�i [ , TYPE OF ROOF COVERING
CITY&ZIP J 'Y" {ryb
6T'/ 97d-
'/ EXISTING
PHONE o e) 9 7n, T �� BUILT-UP ROOF - ElLICENSE 6-13 O 0
fir
NUMBER ASPHALT SHINGL ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Cotle,and my license Is in full force and
effect. /
�s WOOD SHINGLES
01
License Class 0, 3 Lia Number v O � "
Z3 - (o t C.��' OTHER(SPECIFY)
Date Contrecfar
OWNER-BUILDER DECLARATION A121996
1 hereby affirm that I am exempt from the Contractor's License Law for the following reason. PROPOSED(Sec.7031.5,Business and Professions Cotle: Any city or county which requires a permit toconstruct,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 Io the provisions
' of the Contractor's License Law(Chapter 9(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
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to CITY Or UrtHI NO
e civil penalty of not more tfi.Ly�O
e hu ed dollars($500).1: WOOD SHAKES ❑
❑I,as owner of the proprmy loye99s with wages as their sole compensation,will do
the work,end the structurentor Wered for sale(Sec.7044,Business and Profes-
sions Cotle:TheContrectoa does not apply to en owner of property who builds orWOOD SHINGLESImproves thereon,end whouch 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-builtler will have the burden of proving that he did OTHER(SPECIFY)
not but Id or improve for purpose of sale.).
❑I,as owner of the property,em 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. lv
apply to an owner of properly who builds or improves thereon,and who contracts lar such projects
with a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sac. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: ng
1//z
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation,
Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this !O `�r� / �--(�� ,• ��
permilis' sued. / o Seismic
eve antl will maintain Workers Compensation Insurance,as required by Section 3700 of /
,t a Labor Code,for the performance of the work for which this permit Is Issued.My Workers Total
CampersLabors n Insurance performance
and Policy number are; .�J. i'//��
Carrier PolicyNu76L7&LL303Z� PERMIT AUTHORIZATION DATE
CERTIFICATE 6F EXEMPTION FROM WORKERS'
I COMPENSATION INSURANCE NC.❑
(This section need not be completed If the permit Is for one hundred dollars(8100)or less.) {O�L3 • )p
I 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 Call. All roofs sh a inspected prior to any roofing material being
fornix. installed. If a roof is installed without first obtaining an
Date dbPA r inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply P Y p
with such provisions or this permit shal8be deemed invoked. source regulations.
I certify that I have mad this application and stale that the above Information Is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction and roof coverings class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
speWe)aurposes. N - - n , /� �3I�/
(We)agree s save,indemnity and keep harmless the City of Cupertino against liabilities, LCiG�diL 1�
• of the gran costs and expenses which may in any way accrue against said Ciry in consequence SIGNATURE OF APPLICANT DATE
of the granting of this permit.
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 BE PROVIDED FOR INSPECTION
OFFICE COPY