R 6016PERMIT R_ 6 016
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
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
NAME C7 i Y S IN /Yf l7
ADDRESS
lTM a zlPIn�•'0,ao`,, b S 77 , SQ—„7 f osrC,9 -
PHONE 1 L�cJ V 7 S a
LICENSE 6 /V Z>
NUMBER CO
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a (commencing with Section
7000) of Division 3 of the Busnass and Professfons Code, and my license Is In full force and
effect.
UcenseeCCllass r; / LIC. Numb r Z
Date `r �r' Contract
OWNER -BUILD RDECLARATION
I 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
cormlrucL alter, Improve, demolish, or repair any structure, prior to Its Issuance, also requires the
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Lew (Chapter O (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 sols compensation, will do
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Proton.
alone Code: The Contractors License Lew does not apply to an owner of property who builds or
Improves thereon, and who does 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
Is sold within one year of completion, the owner -builder will have the burden of proving that he did
not build or Improve for purpose of sale.).
❑ I, as owner of the property, em exclusively contracting with licensed contractora to construct
the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not
apply to an owner of property who bullds or Improves thereon, and who contracts for Such projects
with a contractor(s) licensed pursuant to the Contractors License Law.
❑ 1 em exempt under Sec. IS It P. C. for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following dectaratlon:
❑ I have and will maintain a Certificate of Consent to self -Insure 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. -
❑ 1 have and will maintain Workers 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
camps/n�pif n Insurance carrier and Polic number a/ja: O! y R [,t 4 (� /1
cerdal�/01"I'l Imo. —/1� irTi7.f/ Policy Nlo�/`�1yfG
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NO.[]
(This section need not be completed It the permit is for one hundred dollars ($100) or lees.)
I certify that in the performance of the work for which thls permit Is Issued, I shall not employ
any person In any manner so as to become subject to the Workers' Compensation Laws of Cell-
fornia.
Data Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become
subject to the Workom' Compensation provisions of the Labor Code, you must forthwith comply
with such provisions or this permit shell be deemed revoked.
I certify that I have read this application and state that the above Information Is correct. I agree
to comply with all city and county ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
e, Indemnify and keep harmless the City of Cupertino egalnst Ilaton3les,
expenses which may In any way accrue against Said City In consequence
PLYWOOD:
RESIDENTIAL COMMERCIAL OTHER
YES ❑ If yes — I understand that a Class A .
roof assembly is required.
NO n Initial I.C.B.O. N
NUMBER OF EXISTING COVERINGS
TO BE RE
EXISTING
BUILT-UP ROOF
ASPHALT SHINGLES
WOOD SHAKES
WOOD SHINGLES
TO BE RETAINED
OTHER (SPECIFY) ❑
BUILT-UP ROOF
❑
ASPHALT SHINGLES
❑
WOOD SHAKES
�1/
WOOD SHINGLES
❑
OTHER (SPECIFY)
❑ _
PROVIDE I.C.B.O. REPORT NO.
PROVIDE MFGR. INSTALLATION SPECS.
APPLICATION DATEI VALUATION I PERMIT FEE I
.Q Building a7_
3ry l U ! ��.pi 8 G Seismic
aua no Atim Total
PERMIT AUTHORIZATION DATE
�1 IIY
t�ol�rA -T. 11 $_3 ��
/An roors snan De Inspectea prior to any rooting matenat.Debng
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 regulations.
��All r f co Sr�gs It jclass gor better.
_�_ 9 -3 -pp --
SIGNATURE OFAPPLICANT DATE
(NSP. 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