R 6089 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 6089
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• r 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDR^^ESSII//
r�1 rJCaS orty TLACE, RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
//�� 11 YES ❑ If yes—I understand that a Class A.
NAME 4=AA1ZL>✓c roof assembly is required.
r,A NO jQ/ Initial I.C.B.O.Is
ADDRESS Ao.-rvs Md.V�tr�u WA;k?Sxk'CATO®rt1 EXISTING ROOF COVERING
PHONE X40$) QS07o NUMBER OF EXISTING COVERINGS k
CONTRA�CATOR'
'•\a� TO BE REMOVED TO BE RETAINED
NAME ATCT%Ae Z�I1�CTin�j,5
ADDRESSTYPE OF ROOF COVERING
CirvazIPP- �MOlcr S Q+iic - cts) a(o EXISTING
PHONE C LieO 9q5" o0lioZ BUILT-UP ROOF ❑
CENSE
NUMBER
S( lq ASPHALT SHINGLES
❑ "
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commending with Section ODD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is In lull force and
effect. 'I�License Claes b$aMe fI Lic.Number S` 1Q V �
INGLES ❑
Date
g I I �' OTHER SPECIFY
(� qg Contractor .�' �A�---�� . (SPECIFY) ❑
OWNER-BUILDER DECLARATION ED
I hereby affirm that I am exempt from the Contractor's License Law for the following rens
(Sec.7031.5,Business and Professions Code: Any city or county whichLr
r to
con struct,alter,improve,demolish,or repair any structure,prior to its issuerequ -B UP ROOF ❑
applicant for each permit to lila a signed statement that he la licensed putse pof the Contractor's License Lew(Chapter 9(commencing with Section 700lo PI theBusiness end Profeealons Code)or that he Is exempt therefrom antl thethe alleged LTSHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit sugpg4ept to '199a civil penalty of not more than live hundred dollars(5500)): saj��,❑1,as owner of the property,or my employees with wages as their soletion,will do W $HAKE$the work,antl the structure le not Intended or offered for sate(Sec.7044, antl Profes.atone Code:Tne Contractors License Lawtloee not apply to en ownerotpho buil ds or WO SHINGLES ❑
improves thereon,and who does such work himself or through his own emrovided thatsuch Improvements are not intended or offered for sale.If,however,the bula sold within one year of completion,the owner-builder will have the burdene d OTHER(SPECIFY) El
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 Contractor's 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($)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B B P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DA VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: 13 7
❑1 have and will maintain a Certificate of Consent to sell-insure for Workers Compensation, Building
137
provided for by Section 3700 of the Labor Code,for the performance of the work for which this Q/�
permith v and (� Seismic �
❑ have and orill the performance
rmancWorker's f the wa tionkfor Insurance,as rmit Is I by Sectiod.My
3700's J
tea Leber tiotle,for ins performance of the work for which this permit la lasuatl.My Workers 1341
41aa
Compensation Insurance carrier and Policy number are; /y Total V
Carrler�MTETtJ)I1, Policy No. 210L96 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 1001 o l
(Tele section need not be antecompof the
If the permit Is for one permit
hunis i sued,(shall 7 or lase.) J (VVt
certify that In the performance of ilia work for which this permit IS Issued, shall not employ `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
fornia.q AI installed. If a roof is installed without first obtaining an
Date 1—1 Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,after making this Certificate of Exemption,you should become Applicant understands and will
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP comply P Y with all non point
with such provisions or this permit shalfbe deemed revoked. source regulations.
I certify that I have read this application and state that the above information Is correct.)agree
to comply with all city and county ordinances and stale laws relating to building construction.and All roof coverings to be class;01 or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spe)agrPosea.
(W
(We)ogres tos save,indemnify and keep harmless wa the City ai Cupertino y inagainst liabilities,
enceof
the granting
costa and expenses which may In any way accrue against sold Clry In consequence 1
• of the graining of Clea perms. SI�@MATURE OF AP (CANT DATE
PRE-INSPECTION: PLYWOOD:' IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: - BATTKNS: FINAL:
INSP.—DATE INSP. \ DATE INSP.' DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY