R 6004 APPLICATION FOR CITY OF CUPERTINO.
NUMBER PERMIT
R- 6004 ,
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
/) 1I
&l^7/Na RESIDENTIAL COMMERCIAL OTHER
OWNER'S 1� HAZARDOUS FIRE AREA
j +_ YES ❑ If yes—I understand that a Class A
NAME 1 1-_1 YI 10 L�.PGr roof assembly is required.
n r n + 9 No ❑ Initial I.C.B.O.11
ADDRESa' 677��� /I. V ua Fes( L_c,lpp ,tto EXISTING ROOF COVERING
PHONE 7_7— NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME /(j 11 L///gyp/1S lLCl7 TO BE REMOVED TO BE RETAINED
ADDRESS (707L ! V& TYPE OF ROOF COVERING
CITY&ZIP 1 O -
EXISTING
PHONE 73 dZ 7 BUILT-UP ROOF ❑ -
LICENSE '
NUMBER l3 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Profeselana Code,and my license Is In lull farce and
effect. 3 WOOD SHINGLES ❑
License Cles9c-3� Lic.Num
Date 7 f.90-9$" Contras OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that I em exempt from the Contractor's License Law for the following reason. -
IS
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
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Law(Chapter B(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 O14
49 exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to 4
e civil penalty of not more than five hundred dollars($500).): J
El 1,as owner of the property,or my employees with"gas as their sola compensation,will do WOOD SHAKES
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profas- Jt '�
Bions Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES vT�
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 C .,1JJ., I � J
is sold within one year of completion,the owner-bulltler will have the burden of proving that he did OTHER(SPECIFY) Ely9C LI— /
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 Contractors 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(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
El am exempt under Sec. ,B B 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: -sem
❑I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, Z D� Building o'0
as provided for by Section 3700 a1 the Labor Code,for the performance of the work for which this /� ^ (�Q L ,J g � ((''``��
permit Is issued. - / I/ 0 — T / Seismic I s o
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of I
the Labor Code,for the performance of the work for which this permit Is Issued.My Workers Q
Compensation Insurance ce"�e�r e Policy n�"'bf�re: n Total ro
Car(ac"�a/Yn7?M/U �jfG( / Policy IN �M't9g PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' 'I
COMPENSATION INSURANCE N.GO —
(TMs section need not be completed If the permit Is for one hundred dollars($100)br less.) V CJ 1 yJ y `r tIDY
I certify that In the performance of the work for which this permit Is Issued,I shall not emptoy
any parson in any manner so as to become subject to the Workers'Compensation Laws of Call- All roofs shall be inspected prior to any roofing material being
fornix. 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.
1 certify that I have read this application and state that the above Information is correct.)agree
to comply with all city and county ordinances and state law&relating to building construction,antl - All of coverings be class' or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In- "'7
spectionpurposes. Fe
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City in consequence
Of the pranting of this permit. NAT RE OF APPLICA 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