R 6058 PERMIT R_ 6 0 5 8 .
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 ADDRESS
UAS VrNcihs %,J RESIDENTIAL COMMERCIAL - OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME t',4 iM'�x V_W A'I'D VES ❑ It yes—I understand that a Class A
roof assembly is required.
NO ❑ Inmal I.C.B.O.q
ADDRESS 103f" LAcS Ci;-4x>r wM.I EXISTING ROOF COVERING
PHONE 2573 ^ NUMBER OF EXISTING COVERINGS
CONTRACTO1 R,'SS -
NAME v" TO BE REMOVED TO BE RETAINED
ADDRESSI -' /� TYPE OF ROOF COVERING
L-46 CITY&ZIP 1004 —46 Qn. "5 IJAdn .
EXISTING '
PHONE 2-SZ - 5 1 2,a BUILT-UP ROOF ❑
LICENSE
NUMBER 4-iq O xT zi ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am 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
affect. C-39 WOOD SHI aii�;c
License Claes Lec.Number 7
$'� 7 G8 ��d�— OTHER(SP C )
Data r ( Contractor OWNER BUILDER DECLARATIONPROPOSEDhereby elfirm that 1 am exempt from the Contractors License Lew for the uires a reason.(Sec.7031.&, ,Improv antl Profeolish,or rep Cotle: Any dry or county which requires a permit toconstruct,alter,Improve,demtofile si or dstatem structure,prior to Its les rsuant alsoe provi i theBUILT-UP RO
appllcent for etch permit a file a signed r 9(co m that g Is licensed p 1011ofto the pro atIleof the ss an Pro License Lew(Chapter h(commencing with Section 7000)of Dlvlethe 3 of the
exa ptio and violation f Code)ar that he la exempt therefrom end the baste for the alleged ASPHALT SHI d (� .
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
hundred
e civil penalty of not more than floe hundred employees
(h wag): WOOD SHAKES 1,as owner stheproperty,tI to ded or oaewith wages as their 7 sole compensation,.111 do ❑
thesio work,and the structure Is not Intended or offered for safe(Sea owner
of Business entl Proles-
ImproCode:The,and
Licence Lew does not apply toenowner ofproperty who builds or WOOD SHINGLES
Improves o(hereon,n,entl who does such work himself or through his own employees,tholeor provided that ❑
such Improvements are not completion,
leb n,or offered for leer.ill however,the entitling o i Improvement
Is not build
ld or I provne e for purpose
s le.).he owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor($)licensed pursuant to the Convector's License Law. PROVIDE MFGR. INSTALLATION SPECS.
0 I am exempt under Sec. ,B&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 have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, BUlldln
as provided for by Seddon 3700 o1 the Labor Code,for the performance of the work for which this g
permit is Issued e
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of t 9 / 0 • Seismic
the Labor Code,for the performance of the work for which this permit is issued.My Workers
Compensation Insurance terrier and Policy number me: Total ('
Carrier STA'f4 PA^,C(, PogcyNa. 1LtF13by-93 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C. �14 g
(Tele section need not be completed of the
II the permit Is for one nnit is Issued,dollars shall nor leeso a
1 perso them the performance of the work for which W permit ie Impel shell not employ
any person m any manner so as ro become subject to me workers'campaneanoa Lewd of can- All roofs shall be inspected prior to any roofing material being
fornia n installed. If a roof is installed without first obtaining an
Datef 7 �'� Applicant �✓�"� inspection,I agree to remove all new materials for inspection.
NOTICE TO PUCANT: If,alter making this Certificate of Exemption,you should become
Subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit Shall be doomed revoked. Source regulations. -
I tartly that i have read this application and state that the above Information IS correct,l agree l
m complyyauthorize
rep and county of this coy and ter upon
the
to buildinged property
f and All roof g CIBSS`Q"Or better.
to with
hlxe city and county of this cies to enter upon the above-mentioned property for In.
spection
We) purposes. 8 4
(We)spree s save,expenses
and keep I harmless wa the City of Cupertino against liabilities, +/T/!/ C
jus menta,coats and expanses wNch may In any way accrue against said Clry In consequence
of tie 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