R 6277 PERMIT R_ 6 2 7 7
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
RESIDENTIAL COMMERCIAL OTHER
OWNER'S .yn / HAZARDOUS FIRE AREA
NAME �9c.,ti1 / ro �.rT _ YES ❑ If yes-I understand that a Class A -
V f p1 NO roof assembly is required.
❑ Initial I.C.B.O.#
ADDRESS l0 91 O /2
1en V ✓P EXISTING ROOF�COVERING
PHONE NUMBER OF EXISTING COVERINGS L•
CONTRA�C/TORR'S�,� , w/ ) TO BE REMOVED TO BE RETAINED
NAME�i�%��iCJY/t/f7"��I/Sj�7/✓/FON
ADDRESS� /' J , l S� dlr� s/F. 9yro� EXISTING
TYPE OF ROOF COVERING
CITY 8 ZIP !T !-J�7
PHONE 4,e/ r — 777 -1 ,e-73, y BUILT-UP ROOF
LICENSE
NUMBER S2�� ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
1 hereby inion that em licensed under Professions
of Chapter B(commencing with Section WOOD SHAKES
]000)of Dlvlelan 3 pl the Business and Profeealona Code,end my license Is In lull lone antl
affect. WOOD SHINGLES
_ ❑
License Claes 9 Lie.Number
91
Date Cont
�_ Q (I OTHER(SPECIFY) ❑ '�
� J recmr
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to ❑ �� /�
construct,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 pursuam to the provisions
of the Contractors License Law(Chapter a(commencing with Section 7000)of Division 3 of the ❑ �l
• Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES s
exemption.Any violation of Sectlon 7031.5 by any eppllcent for a permit subjects the applicant to
a civil penalty ofMa�e Iles
❑I,asownedi eprrroopq A emplo{e✓tawllh as their sole compensation,will do WOOD SHAKES ❑
the work,and 0 r cture i dad o o ere tl I (See.7044,Business and Profes-
sions Cods:Th raclo icon awIt nota IN an owner of property who builds or WOOD SHINGLES
❑
Improves thereo , r who does such work himself or Mr h hie awn employees,provitletl that
such Improveme e e t daeyg orr�gylfe el �If, waver,the building or Improvement
is sold within on y rot �i ' loy.ihafow9990 II ve the burden of proving that he dltl OTHER(SPECIFY) ❑
not build or Impr for purpose of sale.)).
❑I,as owne the property.am exclusively Contrailh licensed contractors to construct
the project(See 7044,Business and Profession Cotle:Th Contractor's License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an ownh rpparty who builds orimprovea ihereo and who contracts for such projects
withacontre<to s)41Q{iaead. mnttntharnnIre1,,,:eU ense Law. - PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exemptunder ". ,B 8 P.C.for 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:
❑I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, Building00
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this _
permit is Issued. �s s'��.� Seismic
❑t have entl will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit Is Issued,My Worker's 8 2-1
r
Compensation InT�urenc�carrier Pn_d Pfolicy number are: Total
Carrier-1 4 �- 01/ 1AI CO Policy No. Zr/4 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATIONINSURANCE N.C.0 �r
(This section need not be completed If the permit Is for one hundred dollars($100)or leas.) _ //(
I certify that in the performance of the work for which this permit is Issued,I shall not am lay
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell- All roots shall be inspected prior to any roofing material being
forma (� a installed. If a roof is installed without first obtaining an
Datz �f —J / Applicant , —' e inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Offleers of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor code,you must forthwith comply . Applicant understands and will comply with all non point
with such provisions or this permit shallibe deemed revoked. Source regulations.
I certify that l have read this application and state that the above Information is correct.I agree - '
to comply with all city and County ordinances and state laws relating to building Construction,and All roof coverin to be class{'.D"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
ape purposes. - A
(We)
agree to save,expenses
and keep harmless the City of Cupertino against liabilities, /_
ofjudgments,the granting
of and expanses which may In any way accrue against ualtl City n consequence ) /
. of the granting of this permit. SIU OF APPLICANT DA E
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