R 6135 APPLICATION FOR CITY OF CUPERTINO
PERMIT R- 6135 .
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
IV '1 1T�I�y^( �
�?>co I � •r ' ` ` ' —' RESIDENTIAL COMMERCIAL OTHER
OWN Ws HAZARDOUS FIRE AREA
dAW �I A YES ❑ If yes-I understand that a Class
NAME_ W V- NO root assembly is required
tlal� I.C.B.O.#_>
ADDRESS ' Ynl[_Ar4ie�iicn�PEXISTING ROOF COVERING
_ 5 O t NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOR'S I. �/1 �•r�f I/•I /�
NAME ci[O� l V'v� CAJ p TO BE REMOVED TO BE RETAINED
ADDRESS 2 �. I n t/,r�.{•h�.(�!n n._ - / •/� _„ ,� / OO'
CITU 8 ZIP `1 \/1 lU'`L-I t �f(y�,Q„ 1 GfVUTA .IIJ 1 TYPE OF ROOF COVERINGEXISTINGO
PHONE BUILT-UP ROOF - � ❑
LICENSE j//�,� n
NUMBER "�UIY ASPHALT SHINGLES/� x [.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing'with Section WOOD SHAKES //h
7000)of Division 3 of the Business and Professions Cotle,and my license Is In full farce and (/.�"
effect. lWOOD SHINGLES
Licanse CI -1 C Lic.Number (D qa
Date Contractor C4 M (A60
OTHER(SPECIFY) D
OWNER-BUILDER DECLARATION PROPOSED OCT 1 .1998
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Coda: 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 El
app
for such permit to file a signed statement that he is licensed pursuant to the provisions
It the Contractor's License Law(Chapter g(commencing with Section 7000)of Division 3 of the
' Business and Profession.Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES By
exemption.Any violation of Sefton 7031.5 by any applicant for a permit subjects the applicant to
a civil penally of not mare than live hundred dollars(55001.):
ED 1.es 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(Sec.7044,Business and Profes-
°lana Cotle:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that Elsuch Improvements are not intended or offered for sale.If,however,the building or Improvement A
Is sold within one year of completion,the owner-budder will have the burden of proving that he did OTHER(SPECIFY) (�
not bu lid 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 Contractor's 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 contractor(.)licensed pursuant to he Contractors License Law. PROVIDE III INSTALLATION SPECS.
E]I am exempt under Sec. ,B 6 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:
❑ ideaand willmfnt37a of Certificate the
bof Consent to self-Insure forWorker's Compeneatlon, � ®// ^t7/ I� f �� Building i
as provided for byill Section 370001 the Labor Consent
the performance for
work Car ompensation
hthis // (Al `XJ
p mit' Issued. Seismic
hv0 and will maintain Worker's Compensation Insurance,as required by Section 3700 of
,the or Code,for the performance of the work for which this permit is Issued,My Worker's Total
Compensation no. nee c rrier end Palls numA�be`�r�@1�e: q,�
Carrier �t-P.OucyNo. rl 1� ' I PE UTHORIZATIO DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 100)a /O /—L Q
(This section need not be completed If the permit Is for one hundred dollars($100) r leas.) �J
�.
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 Cell. All r0 all be inspected prior to any roofing material being
.f°`me. installed. It a roof Is installed without first obtaining an
Date Applicant - inspection,I agree to remove all new materials for inspection.
subjeT CE ct t.the TO APPLICANT.
mpensetl n provisions of theflLabor CodefCate of °yolu must forthwld become
ith comply Applicant understands and will comply with all non point
with such provisions or this permit shelgbe 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 laws relating to building construction,and All roof
cov rings to be cl ss"O"Ol�befler.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino al Ilabililies,
judgments,coats and expenses which may In any way accrue against said City In consequence
- of the gramIng of this permit. SI GRATURE OF A?PLICJ1,NT V DATE
PRE-INSPECTION: PLYWOOD: IN• ESS:
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