R-5750 PERMIT R_ 5756
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION,
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED.
r -WITHIN 150 DAYS OF PERMIT ISSUANCE OR
1 - 180 DAYS FROM VST CALLED INSPECTION.
BUILDING^ADDRESS
t� C.cf —D4q_rqt,3-zAJ V /N RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ B yes-I undersland that a Class A
NAME roof assernbly is required.
NO ❑ Initial I.C.B.O.11
ADDRESS &I(.4110 S% .6� �'l/ L1—S EXISTING ROOF COVERING
PHONE — 6 e Z,
NUMBER OF EXISTING COVERINGS
CONTRACTORS (� I
NAME 11,) 1�'S - E��T'•�T•1D I-1 S{.S TO BE REMOVED�.J�70 BE RETAINED
CITY,&ADDRESS 1 ( �V l T.0 Ave- �{� TYPE OF ROOF COVERING
PHI�c' EXISTING
e VI9 3 ^ 91 BUILT-UP ROOF
LICENSE
NUMBER O LAS ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Season WOODSH E ❑
71X10)of DMsioo 3 of the Business and Professional Code,and my license Is In full force and
effect. WOODS S ❑
Users Claes Lio.Number n4I . .
Date (6 — Lli gig contractor OTHER(SPECT ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors Uterus Lew for the foliowing meson.
(Sec.7031.5,Business shot Profession Cade: Any city or county which requires a parmd to
conetrocL alter,Improve,demolish,or repair any,aWcture,prior to its Issuance,also requires the BUILT-UP ROOF Q
t applicant for such Permit to file a signed statement that he Is licensed pursuent to the provisions
of the Contractors License Lew(Chapter g(commenGnp with Section 7000)of Division 3 of the
Business entl Pmleeelone Code)or Net he Is exempt ihemhom and the beers roc me eloped ASPHALT SHINGLES ►1 ❑4 AyDsO
exemption.Any violation of Sectlon 7031.5 by any,applicant for a permit subjects the sppicant to - N ANSIi
a cMl penalty of not Tons than five hundred dollars($500).1: ,
❑I,as owner of the property,or my employees with wagee as their sale compensation,will do• WOOD SHAKES CIT,, Uf EL
001 V
the work,and the structure Is rot Intended or offered for sale(Sec.7 ,Business entl Profen- CITY Ch1 I IIY
Nona Cade:The Contractors Ucenm Law does not apply to an owner of property who bulkls or WOODSHINGLES El
thereon,and who does such work himself or through his own employees,provided that
such improvements are not Intended w offered lar sale.If,however,the bullding or Pmptvroment
is said within ane year of completion,the owner-bulioer will have the burden of prwing that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,its owner of the property,em anclustvery connecting with licensed contractors to construct
the project(Sec.70u,Business and Professions Code:The Contractors Uceras Lew dove rot PROVIDE I.C.B.O.REPORT NO.
appy to an owner of property who builoa or Improves thereon,and who cantrecle for such arciecb -
withacontrector(e)licensee pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPE S.Ii!LeMc,
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date IS t..✓�J
WORKERS COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of penury one of the lolkwlng declaration: ' I
-11 have and will maintain a Certificate of Consent to earl-Insure for Workers Compensation; BUlldingSrr11C
60
,,
provided Section 3700 o1 me Labor Cade,for the performance of the Werk for which lite /' /-1 O n .l S6i
❑I have and will maintain Workers Compensation Insurance,m requked by Section 3700 of (� a �.J V
the Labor Code,far the performance of the wok for which this per I t is iS$uW,My Workers
Compensation Insurance terrier and Policy number are: Total
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section meal not ber completed If the permit Is krone hundred dollars($100)tar less.)
I certify that In the performance of the wank for which this permit Is asued,I shall not employ
any person In any manner so xa to became su ed m the a as tiw Laws of call- All roofs shall be inspected prior to any roofing material being
fornix. u installed. If a roof is installed without first obtaining an
,at. 6— I_gB Applicant inspection,I agree to remove all new materials for inspection.
NOTICE a APPLICANT: cher makingthisof
of F�umrou must
tu eorthwithnd dy Applicant understands and will comply with all .non point
subject such
to the Workers'Com mth shall
W dlse d the kebor Code,
with such provolone or this permit�hellndtleemetl revoked. SOUfCe regulations. -
I cera that I have read this application and state that the above Information Is correct.I agree
to comply withal)city and county ordinances and state laws naatlmg to building constwcbon,and All roof COVeri gs t0 class` 'orbetter.
hereby authorize representatives of he city to enter upon the above-mentlwed property for In-
ea.purpoeea.
(We)agree to save,Indermdy,and keep harmless the City of Cupertino agelrat IlabYltlee. Q�l
lutlggma'8 web entl expenses which may in any way accrue against said City n conea tual
of tiro rsnllng,lite perrNL SIGNATURE Or7MPLICANT DATE
PRE-INSPECTION: .. PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. - DATE INSP. DATE
TEAR OFF INSPECTION: // BATTENS:. FINAL:
INSP. "-7 DATEI N INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY