R 6170 PERMIT R_ 617 0
APPLICATION FOR CITY OF CUPERTINO NUMBER
R-
PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN ISO DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
-Z L RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
1 '
//�,a,-n�� �( - YES ❑ Ifyess Iunderstandthat. ClassA
NAME /��' Ste. roof assemhly isarand that
�j -�J NO ❑ Initial I.C.B.O.lt -
ADDRESS-- �,��a1&k&&, AGC EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS /
CONTR TO -
NAMEt / TO BE REMOVED TO BE RETAINED
"Y7� ,
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE �7�61,,�Cg`�yO¢ BUILT-UP ROOF ❑
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that l am licensed under provisions of Chapter a(Commencing with Section WOOD SHAKES rLrJY
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
WOOD SHINGLES ❑
License Close C_3°{ LIc.Number
Date ��—� Q Contractor s sA`,r D!Tli R(Sy'celt r) ILUI f ❑
OWNER BUde: Any
or c O D
I hereby affirm that I am exempt from the Contractors License Lew for the Iollowing reason. ^
(Sec.7031.5,Business and demolish,
or rep Code: Any city or county which requires e permit toconstruc
applicnt,after,Improve,to file signed any h,prior toIts Issuance,also requires the B -UfrRbTOFo ❑
applicant for such permit to file a signedstatement9(commencing
co m that he Is licensed pureuanfto me previsions
Of the Contractors License Law(Chapter h is ex a exempt
with Section 70001 of Division 3 of the �^
• Business and Professions Code)or that he le exempt in tfor a and the jbasisis for the alleged AS ALT.SHINGLES iX
exemption.Any violation of Section five hundred
by any applicant far a permit subjects the applicant to V
a civil penalty of not more then five hundred dollars($500).): By
❑I,as owner of the property.or my employees with wages as their sola Compensation,will do WO S ❑
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Profits.
stons Code:The Contractor's License Law does not apply to an owner of property who bullae or WOOD SHINGLES
improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
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 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 contractor(s)licensed pursuant to the ContraMor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
ownerDate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
'
I hereby affirm under penalty of perjury one of the following declaration: Afte 3 O
❑1 have and will maintain a Certificate of Consent to sell-insure for Workers Compensation, `�..rtj — //// BUlldln
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this V leo o
permit is Issued. Seismic _z
E]I have and will maintain Workers Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit Is Issued.My Workers 3 Q y� f 6Q
Compensation Insurance carrier and Poli umber are: Total
.7 'E
Carrier f ✓ ry(.4 PollcyNo. - �5 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I] fn] 4
(This section need not be completed If the permit is for one hundred dollars($100)or lees.) �p
I certify that In the performance of the work for which this permll Is Issued,1 shall not employ 111 !!!
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
fornia, installed. If a roof is installed without first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after 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 certify that I have road this application and state that the above Information Is correct.I agree
to comply with all city and county ordinances and state laws relating to building Construction,and All roof coverings to be class "o Bitter.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
sp purposes.
we) ��
(We)agree to save,Indemnity and keep harmless the City of Cupertino against Ilebllltlse, ✓
f((ivv�
judpmenls,costa and expenses which may In any way accrue against eeltl Clry In consequence
of the granting of this permit. SIG UR F PPLI T DAT
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 .'