R 6084 PERMIT R_ 6084 -
APPLICATION FOR CITY OF CUPERTINO NUMBER
R—
PERMIT INSPECTION 7 -3228 PERMIT WORK IS
N
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAYS PERMIT ISSUANCE OR
180 DAYSS FROM LAST CALLED INSPECTION.
BUILDING AD RESS '
X0,3
�G'( ` �• RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
Q 1A U YES/j It yes—I understand that a Class
NAME � roof assembly is required
�— • NO ❑ Initial I.C.B.O.1f
ADDRESS L H!h/ `IY.�j` 7 •/ EXISTING _ 1
PHONE p. NUMBER OF EXISTING COVERINGS �S
CONTRACTO///R�Ri
/
NAME 2 0, if TO BE REMOVED - TO BE RETAINED
ADDRESS ///•7 LJ ,/,^ /+ ,// TYPE OF ROOF COVERING
CITY B ZIP_ p -Sg�a�n44 C 1Y60 4*111' U A. .
EXISTING
PHONE YQLf ZSy Yf 3�J BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing i Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In 1 lar a and
anent. Q WOOD SHINGLES El Class C—� Lic.Number `'�
OTHER(SPECIFY)
Date Cant recto ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby allirm 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 pursuant to the provisions
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
' Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT NGL
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to PE
a civil penalty of not more than five hundred dollars($500).):
❑I,as owner of the property,or my employees with wages as their sola compensation,wlli do WOODS S C ❑ D
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes- t � 1 199
slops Code:The Contractor's License Law does not apply to an owner of property who builds or WOODS GL JJJ
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
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER( P�y IFY) ❑
not build or Improve for purpose of sale.). J
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I. .E.
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, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
I]1 have and will maintain a Certificate of Consent to soft-insure for Worker' Compensation, A Building
NZ
as provltled for by Section 3700 of the Labor Code,for the performance of the work for which tole g
permit is issued. ,
rid have and will maintain pert Worker's Compensation the wokfor Insurance,as required by S.MY Worker's's SeISR11C
ih L Dor Code,for the performance of the work for which this permit Is Issued. hs Worker's
Compensation!I-nsurance carrier an Policy number are: Total
Carrier Sf4)e FNN(� Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.E3 �1 ^
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) p Y UY
I certify that In the performance of the work for which this permit Is Issued mall nal employ
any person in any manner so as to became subject to the Workers'Compensation Laws of Cel( All roofs shall be inspected prior to any roofing material being
fernla' 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: It,aher.making this Certificate of Exemption,you should become 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 correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof cover' t class"C"or better.
hereby authorize representatives of this city to enter upon the above-memion0d property for in.
apection purposes.
(We)
(We)agree s save,expenses
and keep harmless the Clry of Cupertino eyelnet liabilities,
judgments,costa and expenses which may In any way accme against said Ciry o consequence
' of the granting of this permit. SIGNATURE A PLICANT DATE
PRE-INSPECTION: ., _ PLYWOOD: IN-PROGRESS:
INSP. l 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