R 6079 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 6079
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRES^S� r�
L LANE' RESIDENTIAL COMMERCIAL OTHER
OWNER'S D k,' HAZARDOUS FIRE AREA
DOrOAL� AN► QQb�[N YES ❑ Ifyas-1understandthataclassA
NAME roof assembly is required. . -
7 NO ❑ Inigal I.C.B.O.R
ADDRESS" 2/U 01" L�N(5 i EXISTING ROOF COVERING
(Q}L1�
PHONE 1 1II�20 sDIO�� NUMBER OF EXISTING COVERINGS
CONTR TOR'S /�
NAME Q$ 1q tt.7�l T REMOVED TO BE RETAINED
ADDRESSZ LaaCO AU 51 ( TYPE OF ROOF COVERING
PHONE 2, 8 "� �J WILT-UP ROOFLICENSE
❑
NUMBER 5S \ Y3a, A�PHALTSHINGLES ❑,
LICENSED CONTRACTOHS DECLARATION [�� —
I hereby affirm that I am Ilcensetl under provisions of Chapter B(dortlho-wiMrs t WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my II riseIs in full force and
affect.
C 2du� � ��` WOOD SHINGLES ❑
License Cclass�f c Q[I, Lid.Number
Det. ^'`'ate `` Contractor-�^�Aye,,yiNaC4r FraGeo. OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
1 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 county which requires a permit to
construct,al ter,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 Lew(Chapter B(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 SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).):
❑L as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sac.7044,Business and Proles-
alone Coda:The Contractors License Lew does not apply to an owner of property who builds or WOOD SHINGLES ❑ (�IONIEK.
Improves thereon,and who does such work himself or through his own employees,provided that p
such Improvements are not Intended or offered for sale.If,however,the building or Improvement I1u(LALt't'E�
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY)
not build or improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO. V✓
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sac. ,B 6 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: 1 /
E]I have end will maintain a Certificate of Consent to self-Insure for Worker$Compensation, Building L I
as provitletl for by Section 3700 of the Labor Coda,for the performance of the work for which this � 1
permit is Issued. �'���
❑I have and will eWorker's Compensation Insurance,as required by Section 3700 0l � W Seismic 1 .70
the pf
,the Labor Code,for the performance of the work r which this permit le Issued.My Workers
a
Compensation Insurance terrier and Policy number are: Total
CernargT&VIV f:rUa1S- Policy No.�Ia u '� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.D
(This section need not be completed If the permit is for one hundred dollars($100)or less.)
I certify that In the performance or the work for which this parmlt Is Issued,I shall not employ —,
any person In any manner so as to become subject to the Workers'Compensation Laws of Ceti. All roots shall be Inspected prior to any rooting material being
feria' installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOT CE eoselmaking
Certificate of
luushould
subject t.tthWorrkers'Cmpena provisions of the Labor Code,you mstforthwlhcomply Appli ant understands and will comply with all non point
with such provisions or this permit shalllbe deemed revoked. $OUr a re UIatIODS.
1 certify that I have read this application and state that the above Information le correct.I agree
to comply with all city and county ordinances and elate laws relating to building construction,and Al Of v Ings acl sS"C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
sp(W proposes. �'_^
(We)agree s save,indemnify and keep hay way the City of Cupertino y in against labIlifies, -{l.�V
of the granting
costs and expenses which may In any way accrue egelnal said City In consequence
• of the granting onhls Parma. � _ IGNATURE 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