R 6260 (2) APPLICATION FOR CITY OF CUPERTINO NUMBER R- 6260
.
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1B0 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
'76 2A L_L8 C R W� c T a RESIDENTIAL COMMERCIAL OTHER
OWNER'S 1 ,/� I ' HAZARDOUS FIRE AREA
NAME ?R�►-I N E C H B N VES l5S Iron assembly st equirede ClassA
NO ❑ Initial I.C.B.O.N
ADDRESS-74-62A eL,bEtL (N GT EXISTING ROOFCOV/—ERING
PHONE 4u --ZS S — I S NUMBER OF EXISTING COVERINGS D ii
CONTRACTOR'S
NAME—J �'t�. R 000— I N G 1C CONS 1 - TO BE REMOVED s'3'I r}C 6 TO BE RETAINED J'F O N L
ADDRESS `,4 5��n�����y ,V, 01t TYPE OF ROOF COVERING
arvazlP_ KT 1
SEXISTING
amir 0S
PHONE- 4oB ^2 T'2 — c7'3 t- 2— s t� y BUILT-UP ROOF ❑
LICENSE 533
NUMBER '3 6 ,sj ASPHALT SHINGLES El
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 lull force and
effect.
WOOD SHINGLES ❑
License Class Lic.Number
(SP"FY
OatsOWNER-BUILDER
D
OWNER-BUILDEROECLARATION I PROPOS. ED
1 hereby affirm that I em exempt from the Contractor's License Law for the following reason. �f p
(Bac.7031.5,Business and Professions Code: Any city or county which requires e permit to r,
construct,alter,Improve,demollsh,or repair any structure,priortolts leauence,elsorequiraetha UILTUP'I�OOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's 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 B ASPHALT SHINGL
exemption.Any violation of Section 7031.5 by any applicant fora permit subjects the applicant to
e civil penalty of not more than live hundred dollars($500).):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work.and the structure Is not Intended or offered for sale(See.7044,Business and Profes-
sions Cade:The Contractors License Lew 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.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 OTHER (SPECIFY) Elnot 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 contractogs)licensed pursuant to the Contractor's License Law.. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B a R 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, �D Building/Z-7
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 4 -pp
permit is issued. Seismic D
F11 have antl will maintain Workers Compensation Insurance,as required by Section 370001
in abor Cotler for the performance of the work for which this permit is issued.My Worker's
Compensation Insurance carrier and Policy number are: D Total
Cerrler ST 14T F ''r l)N D Policy No. a' II76� I d PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NA.D
(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, shall not employ
any person In any manner so as to become sublet to the Workere'Coy eneabon Laws of can- All roofs shall be inspected prior to any roofing material being
fornia. ro / installed. If a roof is installed without first obtaining an
Dale I I�QZ_y'8 Applicant ��^ "ti`��`— inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,alter Maki this Certificate ofrExempti n,you hould become
subject to the Workers'Compensation pr Iblons of the Labor Code,yo rihwlih comply Applicant understands and will comply with all non point
with such provisions or this permit shall Add, revoked. Source regulations.
I certify that I have read this application and state that the above information la correct.I agree
to comply with all city and county ordinances and stale laws relating to building conetruciion,end All roof overings to be class"O"Of better.
hereby authorize representatives of this city to enter upon the above-mentioned properly for In-
spection purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against Ilabhities,
judgments,costs and expenses which may In any way accrue against said City In consequence
• of the granting of this permit. NATURE OF PPL CANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROG
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 _