R-5950 PERMIT' R_ 5950
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT # 2(2) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
2103S rice Q Dr . RESIDENTIAL ,x` COMMERCIAL OTHER
OWNER' HAZARDOUS FIRE AREA
rJ 11th m o r� YES ❑ If yes-I understand hat e Class A
NAM S P T l_�-I 1�T I n f roof essernhly Is required.
v NO ElIniial LOB.O.I
ADDRESS Q EXISTING ROOF COVERING
PHONE �- - NUMBER OF EXISTING COVERINGS
CONTRACT%%TQQ R'S l/ '
NAME `--115 ` 62z,/as �0 TO BE REMOVED I TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP.
EXI IN
PHONE— ,W. 35E�-123 BUILT-UP ROOF :r_1
LICENSE c
NUMBER J ASPHALT SHINGLES
DCENSED CONTRACTORS DECLARATION
I hereby°"Inn met I em licensed under prwlelons of Chapter.9(commencing wlm Section WOOD SHAKES ¢
7000)of Dfvlslon 3 of the Business and Professions Code,and my license is In full force and Cle" WOOD SHINGLES z
License Cleve SLL� Llc.Number �` �5-' '//
Dete Convector OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am m th
exempt from Contractor's iLew for the following reason.
(Sec.7031.5,Business and Professors Code: Any city or county which requires a per Mt to
construct,alter,Improve,demolish,or repair any structure,prlor to its Issuance,also requires the BUILT-UP ROOF ❑
epplk°nt for such pemdt to fib a signed statement that he is licensed pursuant to the provision
. of the Contractors Ucense Law(Chapter a(commencing with Stiction 71)00)of DMeon 3 of the
Business and Professions Code)or that he Is exempt therefrom and the basis for the staged ASPHALT SHINGLES ❑
axempffinn.Any dvti wall of not morefthan ffve hundredion 7031.5 dol al rs�(5`AO).J icant for a permit subjects the applicant to
❑I,as owner al the property,or my employees with wages ss their we compensation,We do WOOD SHAKES �PA I ()
ore work,arN the enucture Is not Intended or offered for seta(Sec.7044,Business and Proles-
elons Code:The Contractors Ucense Lew does not apply to an owner of property who bueds or WOODrowthSHINGLES oC Q O
Improves thereon,entl o does such won,hlmealf or through his own employees,provided that 4 •.`
such Impvements'are not Intended for or offered sale.If.however,fire WMIng or Impoveme
rnt
is sold within one year of completion,the owner-bulkier will have the burden of proving that he dict OTHER(SPECIFY) CII❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,em exclusKTly contracting will,licensed contractor to construct .r yam' L
the project(Sao 7040.Business and Profesalo a Code:The Contractors Llranse Lew dose 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 t(
with atons)lice pursuant tome Conirectore License Lew,
am ex
❑I em exempt underr Sec. B 8 P.G for this reason PROVIDE MFGR. INSTALLATION SPECS.
,
Owner - Dale APPLICATION DATE VALUATION PERMIT FEE
- WOfil(ER'S COMPENSATION DECLARATION -
I hereby affirm under penalty,of perjury one of the following declanagon:
ice p❑rovkecf for by Se maintain
3700 of the LLaaborto iCode sforr be pt to eMn�manancee o Me"M for which this - Building rgW
permit
s issued.
D l lhim and will maintain Workers Compersatlon Insurance,as required by Section 3700 of � ��-�Qj �/�j Seismic ` D
the Labor Code,for the perormence the wok for whichis is
this permit sued.My Wokern 6 Total / o
Compensatl Insurance carriers pce
Cant Policy N,5g r75& PERMIT AUTHORIZATION DATE
CERTIFI ATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 T hh G
(This section road not be completed H the pemdt Is for one hundred dollars(f100)or lass.) �Cr A — `• V '� - Z- I
I certify di In the performance of the worx for which tiJn permit Is Issued,I shell not employ,
any person In any manner so m to become subject to the Workers'Compensation Laws of Calk All roofs shall be inspected prior to any roofing material being
rocni°. installed. If a roof Is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this CeNflcete of Exemption,you should become Applicant understands and will
subject to the Workere Compensation prwielons of me Labor Cade,you must forthwith comply PP comply P Y with all non Point
with such pro hone or this permit shell be deemed revoked. source regulations.
I certify that I hews react this applkaticn and state met to some Information Is correct.I agree '
to comply will all city end county ordinances and state laws relating to bullding Wnetructlan,and All roof cove ' S to be Class"or better.
hereby authorize represennetrvas of Its city to enter upon the above-mentloned property for In- �j
ep(We)aurpoeea. Ii—J G
(We)agree to aeve,Indemnity entl Reap harmless gw City of Cupertino agelnst Ilebllnlea, 0-9
lu the g s,costa and expenses wNch may In any way accrue against said City In mroequence SIGNATURE OF APPLICANT DATE
of the PECTt�ng of N:thiparmt.
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