R 6324 PERMIT R_ 6324 ,
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
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS Le&
Q n�C) ��e&TT ) ` �{� RESIDENTIAL 'x` COMMERCIAL OTHER
OWNERS _1 ( � HAZARDOUS FIRE AREA
NAME y 1 ^ CNA`N C Ili`rAl" YES ❑ If yes—I understand that a Class A
roof assembly Is required.
n NO ❑ Initial I.C.B.O.k
ADDRESS.`�D 3�- -f��'�,�'Q'(' �"Q.' EXISTING ROOF COVERING
PHONE 7T10
,A(-�x�pp NUMBER OF EXISTING COVERINGS I
�
CONTRACTOR'S e ,,� 7//�,,,,/ /�+
NAME JLII3 1%P`, Wi ^'K IN� `10— 1 N C TO BE REMOVED TO BE RETAINED
ADDRESS •L-Lp,Z U COLLA AV �.{ q5��j TYPE OF ROOF COVERING
CITY&ZIPr �J EXISTING
PHONE \a•O�� 6 — �(o� BUILT-UP ROOF ❑
LICENSE ❑
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES to
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect' C \ � WOOD SHINGLES
License Class /� —�7 Lie.Number SS� 36
- ❑
Data I7'_ � - " Contractor atoASAN I OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED �3
I hereby affirm that I am exempt from the Contractor's License Law for the following reason. /
(Sec.7031.5,Business and Professions Code: Any city or count while M1 r 9„a,
construct,alter,Improve,demolish,or repair any structure,pnOtto sissupi also regal as the BUILT-UP ROOF
applicant for such permit to file a signed statement that he ly'Iffooppnsed ay�yI�33�r1�(to the
,Ease
o I510ne
of the Contractors License Lew(Chapter g(commencing�Zh,yecdonAt)00}gfgivlsio� of the D
Badness and Professions Code)or that he is exempt ih r an the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 ay any apPlicen permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500)) nF-r (t �Q� WOOD SHAKES ❑
❑1,as owner of the property,or my employees with wag as th eole�o a ati a
the work,and the structure Is not Intended or olleretl fors I (Sec.7044,Business and Profes.
sions Code:The Contractor's License Lew does not apply n owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or throggh his own employees,provided that
such Improvements are not Intended or offered for sale.II,ho yg r,the building or improvement
Is sold within one year of completion,the owner-builder will . e-caden _ 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 Contractors License Lew 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 contiector(s)licensed pursuant to the Contractor's License Lew. PROVIDE Ml INSTALLATION SPECS.
D I am exempt under Sac. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will malntaln a Certificate of Consent to self-Insure for Worker's Compensation, Building / r
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this p '�7 /'� /
permit Is Issued. I -r7--I Q ' G Seismi
a I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
/ p
the Labor Coda,for the performance of the work for which this permit is Issued.My Work is Total ! a f Z0
Compensations Insurance carrier and Policy number are: [�
Carrier �1 h I'FJ FyMe Policy Na. v+la� Z5 3 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' IF
COMPENSATION INSURANCE N.C.❑
(This section need not be completed it the permit is for one hundred dollars($100)or lass.)
I certify that in the performance of the work for which this permit Is Issued,I shall not employ
any person In any manner so as to become subject to the workers'compensation Laws of can- All roofs shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOT CE subjectt.tth Wor ers'Compens uo promakvisions Ofthis theflcate of LaborrCode,,youmustforthwiithbecome
comply Applic t understands and will comply with,all non point
with such provisions or this permit shall be deemed revoked. sour egulattons.
I certify that I have read this application and slate that the above information is correct.I agree 74
to comply with all city and county ordinances and state laws relating to building construction,and All/10 f goeriltob ass'All better.
hereby authorize representatives of this city to enter upon the above-mentioned property far In-
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City in coneaquenca SIGNATURE OF APPLICANT DATE
of the granting of this permit.
i� PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: /'/ BATTENS: FINAL:
INSP. J-5 DATE�"�r q Ii INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY