R 6246 PERMIT R-
NUMBER .624
6
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 X COMMERCIAL OTHER
-
OWNER'S - - /I HAZARDOUS FIRE AREA
L �U / I 1/ • -per YES ❑ Ii yea s I assembly
is required.
Class A
NAME ( L/ f�/� Ir,�(, roof assemby Is requiretl.
'NO '❑ _ Initial LC.B.D.ft
ADDRESS — EXISTING ROOF COVERING
PHONE LS Z — S.5
S ( NUMBER OF EXISTING COVERINGS
CONTRACTOR
NAME , / l..Y '
TO BE REMOVED Q TO BE RETAINED
� � -(� p -
ADDRESS 10• iQ"_� S LS E' L�✓�L(.t�CVLs -(+�5�3
TYPE OF ROOF COVERING
CITY 8 ZIP O d �/' EXISTING
PHONE \ ` � ��6 - 753 BUILT-UP ROOF ❑
LICENSE �7
NUMBER /� 2 3 3 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 em licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES '
7000)of Division 3 of the Business and Professions Coder and my license Is In full force and +
effect' /' n WOOD SHINGLES ❑
License Cls v Ct Llc.Number- 7 J
Data G 'O 1000 - Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATIqjlr - D
I hereby affirm that I am exempt from the Contractors 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 lis issuance,also requires the V BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provision
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Proleselona Cotle)or that he Is exempt therefrom and the basis for the alleged. T SHINGLES ❑exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).): WOO KES El
theas owner of the property,or my employees with wages as their sole compensation,will do
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Protea- -
slons Coda:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided that ,
such improvements are not intended or offered for sale.It.however,the building or improvement e�•1L /1
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) �' adaw.0
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct p
the project(Sec.7044,Business and Professions Coda:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.E,2 SZ.4
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 Lew. PROVIDE MFGR.INSTALLATION SPECS.
1 am exempt under Sec. ,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:
❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, C Building 10
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
perms is issued. ��Z`G/ /� OQV $e1Sn11C
have antl will maintain Workers Compensation Insurance,as required by Section 3700 of
,t L bar Code,for the performance of the work for which this permit Is Issued.My Worker's Total
Compensetla`�'sum errler antl Palley numb]/ere:
Carrier- ��ite Policy No.W C 2.0 5 Z 74J.3 . PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE
(This section need not be completed If the permit is for one hundred tlollare($100)or less.)
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 Workem'Compenaatian Lawe of coli- All roofs shall be inspected prior to any roofing material being
forms. installed. If a roof is installed without first obtaining an
Date A ' Applicant inspection,I agree to remove all new materials for inspection.
NOTI TOAPPLICANT. If,attar making this Certif1p a of Exemption,you should became Applicant understands and will comply with all non Dint
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP P Y P
with such provisions or this permit shall be deemed revoked Source regulations. -
I certify that I have read this application and state that the above Information is correctI agree '
to comply with all city and county ordinances and state laws relating to building Construction,and All rootsverings to be class 0 or better.
hereby authorize representatives at this city to enter upon the above-mentioned property for In-
speCtiGn purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino e�alnst liabilities,
judymens,coats end expanses wnlcn may In any way accrue against said City n consequence SIG ATUR APPLICANT DATE
ai the granting of Ihla permit
49 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 _