R 6051 (2) PERMIT R_ 6051
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
G— S -2-0 RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME ��Aeb S �p►n/VrCA /��(/(t vas ❑ oyes-IanderstarWtha�aClassA
roof assembly Is required.
NO ❑ Initial I.C.B.O.p
ADDRESS 0 EDW Q2i)y EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'Sp ,(�
NAME 3T ISCo� 1VA11CY A>oF_r j TO BE REMOVED S �'`�S TO BE RETAINED
CADDESSITY&ZIP— 2 s5- 5. W Hi7E' ��• S;S, 9,5� _ TYPE OF ROOF COVERING
EXISTING
PHONE 'Z 2 BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am iiconsed under provisions of Chapter 8(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is In full force and
License
- 2 Q j ` ❑
License Close ��3 � Lic.NumWOOD SHINGLES
ber // / J
$— f
Date Contractor 'T.�z .r OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the fallowing reason.
(Sec.7031.5,Business and Profession.Code: Any city or county which requires a permit to
applicanconstruct forer,
Improve,demoto file signed
or ed airstatement
anystructure,that
he Is licenseor to issuance,alsorequiresprovisions i the BUILT-UP ROOF
applicant lar such permit to filo ah, re statement Ihat he Is licensed pursuant to the provisions
. of the Contractors License Law(Chapter g(commencing with Section 7000)of Division 3 at 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 live hundred dollars($500).): A
[D 1,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 Profen.
sions Code: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 sale.IL 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 sate.). ��`V�
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct C
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.RFQORT'N0.
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 Law. PROVIDE MFGR.INSTALLATION SPECS.
I am exempt under Sec. ,B 8 P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, BUlldln
permit is Is for by Section 3700 of the Labor Code,for me performance of the work for which this nQQ ^ ,_� ^ ^^ w g I /�
permit is Issued. v— /sc./ 'h71 l/V(�f Seismic❑ have and will the pert Worker's Compensation the workfor Insurance,as permit is issued.
Section Workers 0l 1 1
-the Leber Code,for the performance of the work for which this permit le Issued.My Workers Q
STA
Compensation Insurance carrier and Policy number era: /� p Total
Carrier T /fy/,yo Policy Ng. /7 87G�7' �Q PERMITAUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0n
(This section need not be completed if the permit Is for one hundred dollars($100)or less.) � ---� �—
1 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 to become subject to the Workers'Compensation Laws of Call. All roots Shall be IRSpeCte 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,alter making this Certificate of Exemption,you should become Applicant understands and will cont
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP ply with all non point
with such provisions or this permit shalCbe deemed revoked. SOUfCO regulations.
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 All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
speclion purposes.
(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 granting of this permit. SIGNATURE OF APPLICANT 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