R 6632E
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PERMIT R_ 6632
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
_
Ip�2V PI IJO
RESIDENTIAL `/ COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
M�LVI�L-F
VES ❑ If yes -1 understand that a Class A
NAME M m
roof assembly is required,
NO ❑ Initial I.C.B.O. a
CC`
EXISTING ROOF COVERING
ADDRESS�IN0I.F-
PHONE 6_-3
NUMBER OF EXISTING COVERINGS If /
TO BE REMOVED ( TO BE RETAINED a
CONTRA OR's
A _
NAME IJC� W[� LA
�-�IJRI�S,iA
ADDRESS
TYPE OF ROOF COVERING
CITY&ZIP Atte
EXISTING
-j�ri
/�
_`�b/1
PHONE f-1
BUILT-UP ROOF ❑
LICENSE x-34
NUMBER
ASPHALT SHINGL S'--"—"'—❑--- —
WOOD SHAKES ��
LICENSED CONTRACTORS DECLARATION
hereby affirm that am Ilcenaetl under provisions of Chapter 9 (commencing with Section
D
7000) of Division 3 of the Business end Professions Code, and my license is In lull force and
i
effect.
C3 5�
OD SHINGLES JUN �1 99 I�
19
License Class { Lic. Number
-
�q
OT ECI ) ❑
Dale ' I..� Contractor T��r�t�'+A^1Cis AOFI^ie,
PROPOSED By
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Lew for the fallowing reason.
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct, slier, Improve, demolish, or repair any structure, prior to Its Issuance, also requires the
BUILT-UP ROOF ❑
applicant for such permit to file 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
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 ❑
01, 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, Business and Profile.
sions 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
Such Improvements are not Intended or offered for eels. 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 proles (Sec. 7044, Business and ProfeS510118 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 conimctogs) licensed pursuant to the Contractor's License Law.
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 am exempt under Sec. .B & P. C. for this reason
Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
^l �7
1
I hereby affirm under penalty of perjury one of the following declaretlon:
-11 have and will maintain a Certificate of Concent to self -Insure for Worker's Compensation,
00
-?7
Building /J //
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
/ _Zj1 '�
�7 '\�
O O
To—
Seismic
have and will Worker's Compensation insurance, AS required by 3700 of
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f
l
d. My
the Labor Code, for the performance of the work for which This permit Is Issued. My Worker's
th La the performance
Total /
Compensation Insurance carrier and Policy number are:
a
Carrier V!LLAPZNA ti.�(AQC1K PollcyNo.We1-60 .7a6
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 less.)
t7 r
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 10 become 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
Date Applicant
inspection, I agree to remove all new materials for inspection.
Applicayt understands and will comply with all non point
NOT CETOAPPLICANT:
sltmuIII
krCstmaking
mpenaion mstfriowihcomply
subject to he provisions of the Labor Code.
with such provisions or this permit Shall be deemed revoked.
sOUrc egulations. -
I certify that I have read this application and state that the above Information Is correct. I agree
laws to building
ringS 10 a or better.
to comply with all city and county ordinances and state relating 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,
judgments, costs and expenses which may In any way accrue against Said Clry In consequence
IGNATURE 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
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