R 6014 PERMIT R. 6 014 .
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(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
DI7 �)//� ) I _1
• 9 O-7 �" v'✓ " ' ✓�'v� RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES
NAME n�fJly / 7�V Ny! ❑ It yes—I understand that a Class
roof assembly Is required.
NO [] Initial I.C.B.O.k
2 —7 AU1 j8.2 LA06 EXISTING ROOF COVERING
ADDRESS �/ �y —72 7
PHONE LI53 '6 TJ NUMBER OF EXISTING COVERINGS
CONTRALT�/O�1_'S� ^
NAME CF�rVA1 z4.SYj A7L6 F-oGYI LO 7 I a G- TO BE REMOVED v TO BE RETAINED
ADDRESSTYPE OF ROOF COVERING
�/
CITY azip LZ9Z LInTC�LrJ A �ST51
2 EXISTING
r PHONE 44' x+ '���' ' BUILT-UP ROOF ❑
' LICENSE �„7)� ASPHALT SHINGLES
i NUMBER ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 0(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Buslneea and Pfolesslona Code,and my license Is In lull force and
effect.
License Claves LIc.Number �/ LTWOOD SHINGLES '
Date a' Convector J?6PA7t`"3,0c,6 Reali OTHER(SPECIFY)
OWNER-BUILDER DECLARATION - PROPOSED
hereby affirm that I am exempt from the Contractors License Law tar the following reason.
(Sac.7031.5,Business and Professions Code: Any city or county which require,a perm, o
conetfucL alter,Improve,demolish,or repalr any structure,prior to Its laeuanca,also requir the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the Sona
Of the Contractors License Law(Chapter 9(commencing with Section 7000)of Olviel o he
• Business and Professions Code)or that he IS exempt therefrom and the basis for e d ASPHALT SHINGLES ❑
exemption,Any violation of Section 7031.6 by any applicant for a permit subjects the a Ica
a civil penalty of not more than five hundred do are($500).):
El 1.as owner of the property,or my employees with wages as their 8018 compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles- '
alone Code:The Contractor's License Law does not apply to an owner of property who build,of WOOD SHINGLES ❑
Improves thereon,and who does such work himself of through his own employees,provided that
such Improvement&are not intended or offered for sale.II,however,the building or Improvement �7
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER (SPECIFY)
not build or Improve for purpose of sale.),
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct P1
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not NAR IDE .C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractors License Law. FGR. INSTALLATION SPECS. -
❑1 am exempt under Sec. B 8 P.C.for this reason
ownerDate MUTIPN.DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION NPI
I hereby affirm under penalty of perjury one of the following declaration: I Q% I
❑1 have and will maintain a Certificate of Consent to se11-Insure for Worker's Compensation, Ciel
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this ev✓ Buildingt—
P:
la laauetl. t/[�, Z � f
I�have and will maintain Workers Compensation Insurance,tie required by Section 3700 o1 D -1_ 1� `) loo SeISR11C
1 L bar Code,for the performance of the work for which this permit Is laauetl.My Workers
Compensation Insurance carrier and Policy number are: Total
Carrier 4 0)`J A Policy No. I^D 25 3 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION the ON INSURANCE N.C.❑ `-�- ^,^ /�
(Thio section need not be completed If the permit Ie for one hundred dollars($100)ar lase) 0 tl! ,—kit"
I certify that In ins performance of the work for which this permit Is laauetl,I,hell not employ
any person In any manner so as to become sub) tom,Work em'compenaetion Laws of Call. All roofs shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Date g'3'-g� Applloant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: II,after making this Certificate of Exemtion,you should become Applicant Comply
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP ant understands and will Com I with all non point
with such provisions or this permit shall be deemed revoked. sour a 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 eters laws relating to building construction,entl All Of ver gs to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In. /`/ 10
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino apa,n,t liabilities, 1 - —3—
judgments,costs and expenses which may in any way accrue against Bald City In consequence
of me gremmg
is Permit SIGNATURE 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY -