R 6633E
APPLICATION FOR
REROOF PERMIT
NAME 1) /Y1 ft)-0Suu9—A
ADDRESS l0%0-7 491r\ Zr. v'
71
CITY OF CUPERTINO
INSPECTION DIVISION
(408) 777-3228
.'i�J_ILx� /�F3rl�►.�:'77�11i��
ADDRESS �'
CITY & ZIP .A
PHONE _7�
i .
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license Is in fun force and
effect. A !�'
'5159 73
License Class ( �p�C{ \ Lic. Numberp�
Data 1i 72J 1 { Contractor[kwgA`SSANLF FINa
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors 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
applicant for such permit to lila a signed statement that he Is licensed pursuant to the provisions
of the Contractor's 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
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),):
❑ I, as owner of the property, or my employees with wages as their sole compensation, will do
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Busin0as and Profes-
sions Code: The Contractor's License Law does not apply to an owner of prop ilyH lbx edaor.
Improves thereon, and who does such work hlmeall or through his own employ To'Id, d that
such Improvements are not intended or offers tl for sale. If, however,
the
bUft p( mpro2e�/-fiil,
Is cold within one year of completion, the miner -builder will have the burden of 1 gthaM(wdid
not build or Improve for purpose of sale.).
❑1, as owner of the property, am exclusively contracting with licensed cont oto t
the project (Sec. 7044, Business and Professions Code: The Contractor's U a LO 110
apply to an owner of property who builds or improves thereon, and who contra for such prof ct
with a contractor(s) licensed pursuant to the Contractor's License Law.
❑ I am exempt under Sec. .B 8 . C. for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the fallowing declaration:
❑ I have and will maintain a Certificate of Consent to seibinsura for Worker's Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
gl have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
the Labor Code, for the performance of the work for which this permit Is issued. My Worker's
Compensation Insurance carrier and Policy number are:
Carrier VILA -ANOVA Ib6V0ANI4C POIIcy No. kV-Z-O07Q'79is
- - CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed it 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-
fornia.
Date Applicant
NOTICE TO APPLICANT: 11, alter making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
with such provisions or this permit shaltbe deemed revoked.
I certify that I have read this application and state that the above information is correct agree
building to comply with all city and county ordinances and state laws relating to construction, and
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 against liabilities,
judgme me, costs and expenses which may In any way wcruo against said Cityin consequence
of the orantlno of this permit.
INSP.
TEAR OFF
INSP.
DATE
PERMIT
NUMBER R- 6633
PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
RESIDENTIAL / COMMERCIAL OTHER
YES ❑ 11 yes - I understand that a Class A
roof assembly is required.
NO 7 Initial I.C.B.O. k
NUMBER OF EXISTING COVERINGS I
TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
EXISTING
BUILT-UP ROOF ❑
ASPHALTSHINGLES ❑
WOOD SHAKES >
WOOD SHINGLES /6
OTHER (SPECIFY)
PROPOSED
BUILT-UP ROOF ❑
ASPHALT SHINGLES 5�
WOOD SHAKES ❑
SHINGLES ❑
0
I.C.B.O. REPORT NO.
MFGR. INSTALLATION SPECS.
—(APPLICATION DATE( VALUATION I PERMIT FEE
Building za
1149 3 'r Seismic (1 / O
Total IS-A./D
I PERMIT AUTHORIZATION I DATE I
r`2—/ r
All roofs shall be inspected prior to any roofing material being
installed. If a roof is installed without first obtaining an
inspection, I agree to remove all new materials for inspection.
Applicant understands and will comply with all non point
source re lations. J�
All roo ve gs to be cl�Wlycr better.
��ji� �✓r— 6—ZI �'f
SIGNATURE OF APPLICANT DATE
IN -PROGRESS:
INSP.
FINAL:
DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY