R-6713 l
'' PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 6 713
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
1B DAYS FROM IAST CALLED INSPECTION.
BUILDING
rADDRESS /� ,., - �ip
t,6 2- L1l/ �WI�WQQ� 1'./I
RESIDENTIAL COMMERCIAL OTHER
OWNER'S ^ HAZARDOUS FIRE AREA
NAME `dQ�.0 Y t �- Y S ❑ If yeas I assembly
is req that. Class A
/U} - roof assembly isand that
NO Initial I.C.B.O.A
ADDRESS//�� -{, Q/- /� Q U EXISTING ROOF COVERING
PHONE 1,/ •(!v l '� V NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
70 BE REMOVED TO BE RETAINED O
NAME deoLif
ADDRESS TYPE OF ROOF COVERING
CITY 8 ZIP— p1 EXISTING
PHONEI Lq0 //) II�2 n� j '`'r�1 Ul BUILT-UP ROOFLICENSE ❑
NUMBER (O Z Z �I3 I ASPHALT SHINGLES
;E3 CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of 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. 7 WOOD SHINGLES
License Claxss-� Lic.Number `
Date !— J L Comractor _ OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law 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 Elapplicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
• exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES E]❑I,as owner of the property,or my employees with wages as their sole compensation,will do
the on.and the structure is not intended or offered for sale(Sec.7044,Business and Pmfes-
aloneCode:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
improves thereon,and who tloes 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 Contractor's License Law does not PROVIDE I.C.S.O.REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractods)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 LIC VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION ,
hereby affirm under penalty of perjury one of the following declaration: /S)
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this f.n
permit is issued JUL 2 1 / CTS Seismic1.
I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of 9 O
the Labor Cotle,for the padormance of the work for which this permit is issued.My Worker's �" Total
Compensation Insurance carrier and Polic umber are:
Carrier policy Na Z ERMITAUTHO ATION DATE
CERTIFICATE EN EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed if the permit is for one hundred dollars($100)or less.)
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 Cali. All roofs shallibe irfspected prior to any roofing mate 'al 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 TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P Y P
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 building construction,and All roverings to be cla s"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In /1�
apache)purposes. 1///
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities, ,� _ ti(AO
judgments,costs and expenses which may in any way accrue against said City In consequence SIGF RE OF-APPLICANT DATE
of the granting of this permit.
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY