R 6213 ,a
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 6 213
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 �/J �f �� ('
/0 /0j / '�"""• ' 4# RESIDENTIAL / COMMERCIAL - OTHER
OWNER'S HAZARDOUS FIRE AREA
VES 0 If yes-I understand that a Class A
NAMEc {^)x-�7'✓L� C �1,�.r1. // roof assembly is required,
NO
ADDRESS /•+O �/Q//'t.LL+ tel' 1/UM YS� ❑ Initial LC.B.O.N
EXISTING
ROOF COVERING
PHONE e� p3 3 L NUMBER OF EXISTING COVERINGS
G,L(Y) l/ I�RLAit+tXJIA„p- w TO BE REMOVED TO BE RETAINED b
NAME
ADDRESS / ,--. , D t (� I TYPE OF ROOF COVERING
blTv a ZIP
1Ta' EXISTING /
- PHONE ` �3 6 2 BUILT-UP ROOF ❑
LICENSE
NUMBER ;,;L7 31 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION ❑ /�/
I hereby affirm that I am licensed under provisions at Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and /
effect. r q 1 WOOD SHINGLES ❑ /
License Cl�ee�s�`� �•— Llc.Numbar �Z' ✓
Data�`l—Cr 0—Contra or _ OTHER(SPECIFY) ❑ ��
OWNEONIPROPOSED
I hereby affirm that I am exempt from the Contractors License Lew for the following reason.
(Sac.7031.5,Businesx and Professions Code: Any city or county w aquiwe.a
construct,after,Improve,demolish,or repair any structure,prior bs((Tesuancovat8Qrequiras h BUILT-UP ROOF ❑
applicant for such permit to lila a signed statement that he is tic' dq pursuepl t',ote prwlai n
of the Contractors License Law(Chapter 9(commencing with S (:(,I�g0117oX..ofolvh2n 3 of
o I
Business and Professions Coda)or that he Is exempt therefrthe basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for rmit aubet (heap can{{{JJJ
a civil penalty of not more than five hundred dollars($500).): Y/ � � IJ 1p�8 ❑ O�'�
01,as owner of the property,or my employees with we9es ea Ireol Pena lion,wl o WOOD SHAKES
the work,and the structure Is not Intended or offered for sale(S 70041,Business and Profes.
sion.Cod e:The Contractors License Lew does not apply to an er of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through hi own employees,provided that ❑
such improvements are not Intended or offered for sale.It,howev r,:building o. __r Im�gO(
le sold within one year of completion,the owner-builder will have tilt rtla o hedid— OTHER SPECIFY J1.gr GDS
not build or Improve for purpose of sale.). (SPECIFY)
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.70414,Suainess and Professions Code:The Contractors 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 contractors)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 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 self-Insure for Worker's Compensation, v Building /d ��
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this p Q /
per tlaveued. / •�'// s' /�p00 Seismic • .5'O
Al have and will the performance
rmancWorker's f the work
for Insurance,as requiredsu Section 3700 of r
Ih Labor Coda,for the performance of the work far which this permit Is Issued.My Worker's p O
Compensation Insurance c�� �
carrier and/ypli:�ypnumber are: Total led,_Y
Carrier—94 Policy NoWC,,2�dxg8S'ZS PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NAIo
(This section need not be completed If the permit Is for one hundred dollars($100) r lase.) � AC•/1
1 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 became subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected prior to any roofing material being
fornix' /y Y 4� installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
Exem
subject to the Workers'Compensation provisions of tthe11caLaborr..
Code,yoiu mustufo thwllthbecome comply Applicant understands and will comply with all non point
with such provisions or this permit shallf be deemed revoked. source regulations. -
I certify that I have read this application and state that the above Information Is correct.I agree
to comply with all city and county ordinances and state Tawe relating to building construction,and All roof coverings to be class'or better.
herebyauthorizeperp z erepreeentetivee of this city to enter upon the above-mentioned property for In. -i/ ^
ep(We) purposes.
(We)agree tos cave,Indemnify and keep harmless the Clta against
Cupertino y Inagainst liabilities,
judgments,gran,coats and expenses which may In any way accrue against aaltl City In consequence DATE
of the granting otihis permit. SIGNATURE O APPLICANT
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