R 6686 PERMIT R_ 6686
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (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
/b3c� AJ
RESIDENTIALIUl� COMMERCIAL OTHER
OWNER'S _ HAZARDOUS FIRE AREA
, YES El 11
yes-I understand that a Class A
NAME ✓� root assembly is required,
z r /, G+�r NO ri}— Inifial I.C.B.O.N
ADDRESS //j - [! �� �` � V /J ZS EXISTING ROOF COVERING
PHONE IQ Lyto & NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME /" U
ADDRESS L1-V,(ow / C� ; dl TYPE OF ROOF COVERING
CITY&ZIPr�Jy�- 7^/7 !1�/��•+� J EXISTING
PHONE " - ( y" BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALTSHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter a(commencing with Section AWOOD5AKES
7000)of Division 3 of the Business antl Professions Cotle,antl my license Is In full force andeffect. LES
License Class Lic.Number "` "J Date s Z/ Contractor LOWNER-BUILDER DECLARATIONI 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 Ir•��
construct,alter,Improve,demollsh,or repair any Structure,prior to he issuance,also requires the BUILT-UP ROOF Dy _
applicant for such permit to file a signed statement that he Is licensed pursuant to the provlelons ^/
of the Contractor's License Law(Chapter a(commencing with Section 7000)of Division 3 of the B�
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).):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES E]Improves thereon,and who does such work himself or through his own employees,provided that
Such Improvements are not Intended or offered for eels.ll,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) ❑
net build or Improve for purpose of Selo.).
❑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 Lew 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 Contractor's License Lew, 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
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to selb97.00
insure for Worker's Compensation, Building 7
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this ��
permit ISI ed.
ova antl will maintain Worker's Compensation Insurance,as required by Section 3700 0l /� Seismic , •• ��
the Labor Code,for the performance of the work for which this permit Is Issued.My Workers Total 715-
. Compensation Insurance carrier and Policy number are:
f
Carrie j C'^y� Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(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 shell not empjoy
any parson in any manner so as to become subject to the Workers'Compensation Laws of Cali All roofs shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Date Applicant - inspection,I agree to remove all new materials for inspection.
NOTsubject 2theWorkers'CompeE TO APPLICANT: nsationprovlelonsoftheflcate of LaborrCotle.yolumustfothwlithoecome
omply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. source regulations.
1 certify that I have read this application and Slate that the above Information Is correctI agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coveringss ee/.class"C"or better
hereby authorize representatives of this city to enter upon the ebovementlonetl property for In.
spectiort purposes.
(We)
(We)agree to save,expenses
and keep harmless wa ins City a against
Cupertino against liabilities,
judgments,coats and expenses which may in any way accrue egelnst sem Clry Inconsequence SP%TURE OF APPLICA ATE
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
OFFICE COPY