R 6130 PERMIT R_ 613 0
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(ADD+DRESS1 �(
vY `� CUFFo2 D2 - RESIDENTIAL X COMMERCIAL OTHER
OWNER'S J QQ'� M� n HAZARDOUS FIRE AREA
NAME—M/ M r.71 —'sc YES ❑ It yes istand requirad ClassA
roof assembly is required.
NO p Initial . I.C.B.O.7t
ADDRESS T7 III' CLIFFQrc.b b2- - EXISTING ROOF COVERING '
PHONE ZSZ — Z Z NUMBER OF EXISTING COVERINGS r•�
CONTRACTOR'S
NAME_K.6rJA1�bANC( F�Ftr�ln C,_r INS• TO BE REMOVED , TO BE RETAINED
ADDRESSTYPE OF ROOF COVERING
CITY a zip 2Z9Z �f NcoLa Avg„$.�'. R51Z5
EXISTING
PHONE ��� _ BUILT-UP ROOF ❑
LICENSE
NUMBER 55,1:� 36 ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is in full force and
effect. WOOD SHINGLES ElLicense Claes C- `-'� U..Number 55I'�36 n �
Data 9-ZI-98 Contractor &_,)AI SANCQ CDGGIN4 (CO- OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em 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 Its Issuance,also requires the BUILT-UP ROOF ❑ (2/
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
Of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
• exBusinessptio and Any violation of Code)or that he Is exempt applicant and the Coale for the alleged ASPHALTINGL A
exemption,Penalty
of violation more
than
Secfiveion hundred
by any s($5 ant for a permit subjects the applicant m L j�X q _ y
e civil penalty of not mora than flue huntlred dollars($500).): /
❑1,as owner of the property,or-my employees with wages as their sole compensation,will do WOOD Sl ES 1998
I� V
the work,and the structure Is not Intended or offered for Sale(See.7044,Business and Profee. I Scpry �Lf,
alone Code:The Contractor's License Law does not apply to an owner of property who builds or WOODS GLIN
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.If,however,the building or Improvement -
Issoldwithlnoneyearofcompletlan,the owner-builder will have the burden of proving that he did OTHER ( PECIFY) ❑
not build or improve for purpose of sale.). B
❑1,as owner of the property,am exclusively contracting with licensed cant motors to construct l
the project(Sea 7044,Business and Professions Code:The Contractors License Law does not PROVIDE .
apply to an owner of property who builds or improves thereon,and who contracts for such projects '
with a contractor(s)licensed pursuant o the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B a P.C.for this reason
OwnerDate
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 sell-insure for worker's Compensation, Building//7,
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Sy
permit is issued. Z.1`Ib((fi�rr'�� -�7 D L Seismic 7
Jill ave and will maintain Worker's Compensation Insurance,as required by Section 3700 of
theebar Code,for the performance of the work for which this permit Is Issued.My Workors // 7 -7
Compensation�Insurance carrier and Policy number are: Q Total
Carrier Slf\\ts FVN� Policy ND ZGJ-5PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the permit is for one hundred dollars($100)or lees.)
I certify that In the performance of the work for which this permit Is Issued,I shall not employ �L
any person in any manner so as to become subject to the workers'Compensation Laws of Call. All roofsshallbe inspected prior to any roofing material being
lorals. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
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. . SOUI'C regUlatlonS.
I certify(hat I 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 Allr fDDverin SIO be class"C°Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection
mspection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, , 4-
judgments,costa and expenses which may In any way accrue against said City in consequence
. of the granting of this 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY ,