R 6047 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R_ 6047
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1 SO DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDEy/$/'S 4
y �'
RESIDENTIAL—V—COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
j YES ❑ If yes-I understand that a Class A
NAME 1 —' +I roof assembly is required.
NO ❑ Initial I.C.B.O.g
ADDRESS--L 1 7 a vI 'A p. p r EXISTING ROOF COVERING
/
PHONE 'I Of? -Cl -13 991C,
—( O NUMBER OF EXISTING COVERINGS f
CONTRACTOR'S (� 1 P ,(1� ,.,/
NAME I v O Q- T,Imo' 6. I \V C, e V� O�l \, Iy'l/� TO BE REMOVED S 4 TO BE RETAINED
ADDRESS I r -, TYPE OF ROOF COVERING
CITY&ZIP I S S7 � ' tiJ<Z 'Fk of E/ / OS_
3C� b EXISTING
PHONE T �� / BUILT-UP ROOFLICENSE ❑ .
NUMBER 78s `f ( ASPHALT SHINGLES El /
LICENSED CONTRACTORS DECLARATION u
1 hereby affirmthat em n under provisions of Chapter g(commencing with Section WOOD SHAKES
71X10)of Division
on 3 of the licensed
and Professions Code,and my license Is In lull force and
effect. � (
License Class C 3 - Lic.Number `!d 7 y WOOD SHINGLES ❑
Dale g contractor OTHER (SPECIFY)
OWNER-BUILDER DE LARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.703 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 IIIc a elgned statement that he Is licensed pursuant to the provisions
of Ile Conhmctofa License Lew(Chapter a(commencing with Section 7000)of Division 3 of the
• Business and Pro(esslons Code)or that he is exempt therefrom and the basis for the alleged ASPHALT 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).): WOOD SHAKES
❑I,as owner at 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 Proles.slons Code:The Contractor's License Law does not apply to an owner of property who build.or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ❑
ouch improvements are not Intended or offered for sale.It,however,the building or Improvement
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
the project(Sec.7044,Business and Professions Code:The Contractoes 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 contractor(a)licensed pursuant to the Contractor's License Law. - PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&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 self-Insure for Workers Compensation, Q ^ Buildin52.g
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this O �' 1 / 0\v /
permit lav and r/ D `" Seismic �Q
❑ have end will maithe pert Workers f the work
for Insurance,as required by Section 3700's
the Labor Code,for the performance of the work for which this permit le Issued.My Worker's
Compensation Insurence carrier an P y number�are: Total � � 13z
Carrier—S � V,A
t^f / ( Policy No. /y 2^79 a PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed lithe permit is for one hundred dollars(8100)or less.) �Q
I certify that In the performance of the work for which this permit Is Issued,Ishell not employ r+
any person In any manner so as to become subject to the Workers'Compi neatmn Laws o1 can- All roofs shall be inspected prior to any rooting material being
'or 'a
y installig.Of roof is installed without first obtaining an
Dai. Applleent ins�c n,I gree to remove all new materials for inspection.
NOTICE To
LICANT: II,eller making tats rtificete of Exemption,you should become Applicant Nr>, ,e,�ndS and will comply with all non point
subject to the Worker.'C.amen.."."previsions the Labor Code,you moat forthwith comply P�FPry9�r SII p y
with such provision.or this permit sh.1%e deem. revoked.
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 slate laws relating to building construction,and Il roof coverings be class or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In- CII Ur ,UT-L:n 11190
spection purposes. V
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
judgment$,costs and expenses which may In any way accrue against said City In consequence
• of the granting of this permit. SIGNATUREOFAPPLICANT 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