R 6144 PERMIT R_ 6144 .
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT" INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1170 DAYS FROM LAST CALLED INSPECTION. -
BUILDING ADDRESS
IIL40 yWoodJ `VV
creoO- RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
��,,s YES ❑ If yes—I understand that a Class A
NAMEroof assembly is required.
C(
�I�-, ,,,�J 1'1 ,,1�1 NO ❑ Initial I.C.B.O.If
ADDRESS I p(`P-7 t I Lo1r��[�Y�WUW Wy `-T:'.C�f't'— EXISTING ROOF COVERING
PHONE 4Oa�T1 / OJ/ NUMBER OF EXISTING COVERINGS
CONTRACTORS
�.Cr� �,,/'� vV1
NAME X11`� [ J� —Apc� g 111. TO BE REMOVED TO BE RETAINED
ADDRESS
CITY a z P 2 � ��-[7✓Ly1 �01Yk CSG �S�I TYPE OF ROOF COVERING
EXISTING
PHONE ��-9'a-Q45S BUILT-UP ROOFLICENSE
❑
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 0(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
fin• �1 WOOD SHINGLES ❑
License Claes S.K.L_ Lift.Number�(
Date Contrector.
OTHER(SPECIFY) �g� Gl1l
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Lew for the following reason.
(Sec.7031.5,Business and Professions Code: 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 ROOF ❑I,9 /
sopIcent for such permit to lite a signed statement that he Is licensed pursuant to the provisions Y
of the Conlractofa License Law(Chapter g(commencing with Section 7000)of Division 3 of the
Business end Professions Code)or that he Is exempt therefrom end the basis far the alleged /
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to ASPHALT SHINGLES ❑ �y�a•
s civil penalty of not more than five hundred dollara($500).1: ❑ b�
❑I,as owner of the property or rpya a r sole compensation.will do WOOD SHAKES G
the work,and the at of raleTltitTnTenpgd or affere f sale 044,Business and Profes.
Slone Code:The Contra to Ucena 1-A�h. eanot ply toe or of property who builds or WOOD SHINGLES
Improves thereon,and w s su self o rough a n employees,provided that ❑
such Improvements ere til ntletl or offered for sale.I/,how a he building or Improvement
lea to within one earof ellen,the owner. Ileg v h urtlen of provingthat he tlld OTHER(SPECIFY) ,.-.,/ 11Qnf(XJ7
not build or improve for p po ao(,iplgdj 'I ( ) L✓J
❑I,as owner of the pr rty,e el fy contr Ing with ad contractors to construct IV(;� ^�
the project(Sec.7044,B ai ese and Profess ns Cotle:The C orb License Law does not PROVIDE I.C.B.O.REPORT NO. .z[
apply to an owner of prop who builds or improves thereon,and wh contracts for such projects
with a contractor(s)Iicens tl pursuant to the Contractor's License La . PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under a ,B 8 P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
'
d hereby affirm under penalty of perjury one of the following declaration: _
❑I have and will maintain a Certificate of Consent to see-Insure for Worker's Compensatlon, Building/2-7ea provided for by Section 3700 of the Labor Code,for the performance of the work for which this g
permit is Issued.
Vheve and will maintain Worker's Compensation Insurance,as required by Section 3700 of " p['f J J o 0790V!� Seismic
the Labor Cotle,for the performance of the work for which this permit is Issued.My Worker's /r Q
Compensation pInsurance ca�yr.r,iiLer and policy
ynnu�Lmber arre:� Total ( Z
Carrier-lag&OLAlG111/�GY,�tlV PolicyNo. )9�7 PERMIT AUTHORIZATION DATE
CERTFICATE OF EXEMPTIO FROM WORKERS'
COMPENSATION INSURANCE NCO
(This section need not be completed If the permit is for one hundred dollars($100)or lose.) � _g
I certify that In the performance of the work for which this permit Is Issued I shall not employ T
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. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE a APPLICANT,ompe after making
king ihls f the
of ode,you mustufdnhwllthbecome comply Applicant understands and will comply with all non point
subject I.ins Workers'Compensation minions of the Labor Code,
with such provisions or this permit Shall be deemed revoksd. Source regulations.
I certify that I have read this application and state that the above Information Is correct.l agree
to comply with all city and county ordinances and stele taws relating to building construction,and All roof coverings to be classg'or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
apache)purposes. �I/���Q
(We)agree to save,'expenses
and keep harmless the City ai Cupertino y InagaInstcon liabilities, / (J
. 0 he or. costs entl ezmrit. which may In any way accrue against eeltl City In consequence m the grantor. of mla ermn. SIGNATURE OF APP NT 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