R 6176 PERMIT R_ 6176
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
160 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS 1,� /
I O S9 d by RESIDENTIAL ✓ COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA -
tYES ❑ Il yes—I understand that a Class A
NAME IM'r V.in�✓ I=�•t�+ I t r N 2.`� roof assembly is required.
NO ❑ Initial I.C.B.O.N
ADDRESS `I-S-740 A'VVIQy I(oI .s C:7 EXISTING ROOF COVERING
PHONE 1:�. Veta,.JT J C,+ /U 53+ NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S
NAME W&rMS r& (7—r— AJ Cr . zt^ J 1/ T�/C, TO BE REMOVED TO BE RETAINED
ADDRESS' p ,' TYPE OF ROOF COVERING
CITY&ZIP P'o• X �.�J c73 r'•K/AA-P—
Cjpr, EXISTING
PHONE 77-7- `6331 baa BUILT-UP ROOF ❑
LICENSE �.�Z..c1Z ASPHALT SHINGLES ❑ i
NUMBER
LICENSED 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.
q WOOD SHINGLES ❑
License Class `�� 1 Lic.Numb
Date Con �
OTHER(SPECIFY) C
/4
CWNER RDECLARATION, PROPOSED
hereby affirm that I am exempt from the nit rey city a Lew for the following reason.
(Sec.70315.Busines by{r c city my which requires a permit to
W,
after,I ve,demolish abany rclure, Its issuance,also requires the BUILT-UP ROOF ❑
applicant for cuch p lila a lama at he I sed pursuant to the prwislons
of the Contractor's LI a Law doter (commencing h than 7000)of Division 3 of the ❑
Business and Profee (n Code)Or that he Is axe a it and the basis for the alleged ASPHALT SHINGLES
• exemp11o0.Any violet I Becpogzp31 y5 hX}n�nl ermlt auDlects the applicant to
a clv11 penalty of not r he h ntl Ila U r WOOD SHAKES C3
I,ae owner of th costly,or my employees with wage t air Sole Compensation,will do
the work,and the Btru to Is not intended or offered for Bale(Se .7044,Business and Plaids.
Bions Cotle:The Cant or's License Law does not apply to an o nor of property who builds orIII, 4
Improves ❑thereon,end he does such work himself or t s wn employees,provided that WOOD SHINGLES 4��y✓ L/n�f
suchimprovements ar n and er,the building or Improvement
is soldwithin one year nenbuiltler will have the burden of proving that he did OTHER(SPECIFY)
not build or Improve for purpose of Bele.). t�t
❑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 impa thereon.and who contracts for such projects
with a contractons)licensed pursuant to a o re r'a License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. l f ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declara9an: f�'
I have and will maintain a Certificate of Consent to self-insure for Workers Compensation, _/ Building C
as provided for by Section 3700 of the Labor Coda,for the performance of the work for which this
permit isissued. $/y3j, Seismic
C]
I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Cade,loothe performance of the work for which this permit Is Issued,My Workers Total 3 7, -o
Compensation Insurance major and Policy number are: n�snn
. carder S4J9TFGv^l Policy No.285—ra 131 O PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
(This section need not be completed If the permit Is Mr one hundred dollars($100)100)or less.) 0 V
I teddy that In the performance of the work for which this permit ie issued,I shall not employ
any person In any manner sees to become sub a to the workers'Compensation Laws of Cal. All roofs shall be inspected prior to any roofing material being
forma, installed. If a roof is installed without first obtaining an
Data Appli'p,1'yW)/ inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: II,after alekin nla orilllcate of Exemption,you should become Applicant understands and ill comply with all non point
subject to the Workers'Compensation provl ane of the Labor Code,you must forthwith comply pP P y P
with such provisions Or This permll shall be tloomed revoked. source r
I certify that 1 have read this application and state that the above Information Is correct.I agree
to complywlth all city and county ordinances and state laws relating to building construction,and All Of COverin t ass 0 or better.
hereby authorize representatives of This city to enter upon the above-mentioned property for In.
spectlon purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against flabllilies, fl
judgments,coats and expenses which may In any way accrue against said City In consequence gTURE AP NT ATE
• of the granting of this permit. _
PRE-INSPECTION: PLYWOOD: IN OGRESS:
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