R 6081 PERMIT
APPLICATION FOR `„ CITY OF CUPERTINo NUMBER R- 6081
. INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S - .. HAZARDOUS FIRE AREA
p` VES ❑ If yes—I understand that a Class A .
NAME - LfNf6C+�� NO ,6 roof assembly is required. -
Initial I.C.B.O.d
ADDRESS- EXISTING ROOF COVERING
PHONE to_ - NUMBER OF EXISTING COV
/ ERIN GS
CONTRACTOR'S:
n TO BE REMOVED�+�'+«`TO BE RETAINED i 2
NAME Fes+ N
ADDRESS )q3 y; _�� O nQ '/fes gs -TYPE OF ROOF COVERING
CITY&ZIP J ZAC T /_c. L EXISTING
PHONE 494R - a;.
/ BUILT-UP'ROOFLICENSE
❑
NUM ER '(O / - ASPHALT SHINGLES
W ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter a(commencing with Section OOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force entl
, effect.
�Xy "e2 A. WOOD SHINGLES ❑
License Claes I�� Llc.Number_COO 712 • -
B�� — / BAS OTHER(SPECIFY)
! ElDate Contrecfar
OWNER-BUILD ER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractors License Lew for the following reason.
(Sec.7031 5,Business and Professions Cade: 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 ROO ❑ .
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
at the Controctor'a License Law(Chapter B(commencing with Section 7000)of Dlvlelon 3 of the: n
• Business and Professions Code)or that he is exempt therefrom and the basis for the alleged LT S GL
exemption.Any violation of Section 7031.5 by any applicant for 8 permit subjects the applicant to -
a civil penalty of not more than five hundred dollars($500).): OD SHA
❑I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
sl
the Co and the structure is not Intended ores not for sale(Sec.7044,property
and Proles-•hat xv zx 5yyp ❑
clans Code:The reo .anwho d Licence Law doesnotapply toenowner ofproperty whobuilds idedtof IC•fLM1/'y0• NrLXa L—E_S
such
roves o thereon.s are
who doessuchor ofrk fend f ell or .rough It,however,
his own employees,doingor provided ant
such Improve mentaere not platin,orownetlbur sale.It,however,theenof pros Improvement -
Iesold within tbuildorImpeyearofcompletofstheowner-bulltlerwill have the burden of proving that he did OTHER(SPECIFY
❑
not bulitl or Improve for purpose of eelaJ. e '
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Lew does not 8] .B.O.REPORT NO.
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 em exempt under Sec. ,B&P.C.for this reason
Owner Dale
WORKER'S CATION APPLICATION DATE VALUATION PERMIT FEE
'- OMPENSATION DECLAR
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to selbineure for Worker's Compensation, (p Building //
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is leaned. a 3 / ��D Seismic
❑1 have and will the performance
Workerrmancee f the work
for Insurance,as required by Sectiod.My
Workers s a
70
the Labor Coda,for the performance of the work for which IhI9 permit Ia.laeued.My Warkera
Compensation Insurance carrlecand Policy number are: Total 11—J 7
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p D "
(This section need not be completed If the permit Is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit Is Issued,I shall not employ ✓�•r"� VV
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell. All roofs shall be inspected prior to any roofing material being
forms. installed. If a roof is installed without,first obtaining an -
Date Api flcanl inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: II,after making this Certificate of Exemption,you should become Applicant understands and will.comply
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply. pP ply.with all non point
with such provisions or this permit ehall)be deemed revoked."' - source regulation S. -
I certify that l have read this application and state that the above Information Is correct,l agree
to comply with all city and county ordinances and state laws relating to building construction,and ,All roof COV - gs to bac as AMY or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection(We)agree to save,indemnity and keep harmless the City a against
Cupertino sid epelnel Ilabliltles. /� O
judgments,costa and expenses which may In any way accrue against aeltl Clly In consequence of the granting of this permit. /SPNATUREyAPPLICANT DATE
. PRE-INSPECTION: PLYWOOD: i 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 '