R 6125 ERMIT
APPLICATION FOR clry of cuPERTINo
NUMBER R- 612 5
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
BUILDING
180 DAYS FROM LAST CALLED INSPECTION.
ADrDR)ES2S /�/� STA
/+�}^
f - I ✓TA D C{ . RESIDENTIAL COMMERCIAL OTHER
OWNERS HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME EI U-�f - P�'AIL- roof assembly is required.
NO ❑ Inibal I.C.B.O.#
ADDRESS--10 '✓(VO AM10>"4AIS CV' EXISTING ROOF COVERING
PHONE O +46 NUMBER OF EXISTING COVERINGS .--
CONTRA�CTO"R'S fJ
NAME K--rc.IJHldfngNC4� Ir-WFING Co. I NG TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
cITY&zIPZZ L L1rJGOL r3 AUL. 0Yy gSIZS
(q o 4K -a(fa-7- EXISTING
PHONE BUILT-UP ROOF ❑
NUMBER rJ S��3G ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
L 3�1 5179' 36 WOOD SHINGLES
License Close Lie.Number -
10-IS�g� &rJAK SAlICA 'e 0 1 Co. OTHER(SPECIFY)
Data Contractor
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that I am exempt from the Contractors License Lew for the following r
(Sec.7031.5,Business and Professions Code: Any dry or county which requires e p halt to �1
conetruc6 after Improve.demolish,or repair any structure,prior toIts Issuance,Id"rqul e e BUILhWpR ❑
applicant for such permit to file a signed statement that he la licensed pursuant to the pro a LLJJ
of the Contractor's License Lew(Chapter 8(commencing with Section 7000)of Division e
• Business and Professions Cotle or that he Is exempt therefrom and the basis for the I of ASPHALT GLES
exemption,Any violation of Section 7031.5 W any applicant for a permit subjects the spiel o OCT
T
a civil penalty of not more than five hundred dollars($500),): 1 ❑
I,as owner of the property.or my employees with wages as their sole compensation Il do 1'x'OVV JI"I
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and lee-
slons Code: The Contractor's License Law does not apply to an owner of property who IIds or WOODSHING ES ❑
Improves thereon,and who does such work himself or through his own employees, rovl t
such improvements are not Intended or offered for sale.If,however,the building or Pmar
Is sold within one year of completion,the owner-builder will have the burden of proving that he did FY) ❑
not build or Improve for purpose of sale.).
I,as owner of the property,am 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. '
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contrectods)licensed pursuant o the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B S P.C.or this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration;
0I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, Building
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this 7
permit
hvissued. 1 'O'Z�L Seismic
have entl willfor the
Workers f the work
for Insurance,as required u Section 3700 of I b i / D ..++YY / O
,the Labor Code,for Inc performance of the work lar which this permit le Issued.My Workers
Compensation Insurance carrier and Policy number are: Total
Carrier�l^`r PrQ1Vh Policy No. T4"I'� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the permit Is for One hundred dollars($100)100)or lose.)
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 Lowe of Call. All roofs shall be inspected prlorto any rooting material being
lornis - installed. It a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICsubject to Eh Wke 'APPLICANT:Comp ,after ensation on provisions at theflcate of Laborr Code,Exemption,
mustuforthwlitthbecome
comply Applicant understands and will Comply with all non point
with such provisions or permit shelf:be deemed revoked, souWe regulations.
I certify that I have read this application and state that the above Information Is cc'
rect.I agree
to comply with all city and county ordinances and state laws relating to building constructlon,and All o overings to be class"or better.
hereby authorize representatives of this city t0 enter upon the above-mentioned property for in-
spection purposes. f/ /
(WB)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,
7i dgments,coats and expenses which may In any way accrue against said City In consequence
of the granting of this permit. S GNATURE OF APPLICANT 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE.COPY