R 6076 /otoo N Ave S4 17
APPLICATION FOR CITY OF CUPERTINO
NE BRMIT ER R- 6076
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-9228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRES(,SJ 1( oror
O/O / RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME�J /L./ YES ❑ If yes—I understand that a Class A
roof assembly is required.
! NO ❑ Inibal I.C.S.O.K
ADDRESS F �I/N4. S j EXISTING ROOF COVERING
PHONE 0 961 3 0 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
/ _r R //
NAME C 1 ct Coin kr L., 1 PATO BE REMOVED TO BE RETAINED
ADDRESS3 p 7 (? U�� TYPE OF ROOF COVERING
CITY BZIP- O �.]
2 EXISTING
PHONE Y0 ✓67Z 1 ( BUILT-UP ROOFLICENSE
❑
NUMBER / ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION /
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES IL7n/
7000)of Dlvislon 3 of the Buelneee and Professions Code,and my license is In lull force and,
enact. r (/// _ ^y //� 7 WOOD SHINGLES ❑
License rS� Llc.Number
Date G�� ZS7—S g C�. (��, � OTHER(SPECIFY) ❑
Contractor /
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that am exempt from the e: Any city or county
Lew for re requires
ng reason.
(Sec.7031.6,Business and Profedemolish,
or rep Code: Any city or county which requlree a permit to BUILT- OF ❑ �//
construct,alter,Improve,tlemolleh,or repair any structure,prior to Its Issuance,also requires the CCC
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions �s�
of the Contractors License Lew(Chapter a(commencing with Section 7000)of Division 3 of the
• Business and Professions Code)or that he is exempt therefrom and the heels for the alleged <AS SHIN ESexemptionAnyviolation of Section 7031.5byany applicant fore permitsubjects theapplicamto
a civil penalty of not more then five hundred dollars($500).): �FJAKEa❑I,ea ownerof the property,or myemployees with wages ee IhelrBole campenaatlan,will tlo 'U ❑the work,and the structure le not intended or offered for sale(Sec.7044,Business and Profes.alone Code:The Contractor's License Law does not apply to an owner of property who bulltls or SI- LES OImproves thereon,antl who does such work himself or through hie own employees,provided thatsuch Improvements are not intended or offered for sale,ll,however,the building or Improvement 11,le sold within one year of completion,the owner-builder will have the burden of proving that he did R(SPEC IFJ�f9 ❑
not build or Improve for purpose of sale.).
❑1,as owner of the property,am exclusive ly contrecting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVI C.B.O.. R 0.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractoge)licensed pursuant to the Contractors License Law, PROVIDE M .IN CATION SPECS.
❑1 am exempt under See. ,B$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, 7
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this �^ Building 7
perms Is issued. -y ) r �, G Seismic210
❑ have and will the pert Worker's Compensation the workfor Insurance,as required Is
by Section Workers
s o Lye J
the Leber Cotle,for the performance of the work for which this permit Is 169ued.My Workers @@
Compensation Insurance carrier and Policy number are: Total � a
Carrier �4lOyZA J C__ Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O ^
(This section need not be completed If the permit Is for one hundred dollars($100)or leas.) 2 ^ ^ Q V
I tartly that In the performance of the work for which this permit Is Issued,I shall not employ CCCJJJ O
any person in any manner so as to become subject to the Workers'compensation Laws of Can- - All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date 7 O Applicant/--``:.�b�C��i!/� inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: II,after making I a Cartllicete 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 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 bulltling construction,and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for
ape Wpurposes. ,,,
(Wee))agree to save.Indemnify and keep harmless the CIN of Cupertino aggainst Ileblliliee,' �-�//
judgments,coats and expenses which may In any way accrue against said City In canaequence
. of the granting of this permit. SIGNATURE 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