R 6065 (2) 1
PERMIT R
APPLICATION FOR CITY OF CUPERTINO NUMBER . 6065
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1 S DAYS OF PERMIT ISSUANCE OR
ISO DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS j.�( l f
O jl ' `I N G r� [
�p
L RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
(L W A 1 1/' I 1,/1 - YES f 4 If yes-I Understand that a Cla s
NAME_ r-1 IV l7 1_ I 1" roof assembly is required.
NO ❑ Initial - I.C.B.O.N
'ADDRESS
o 3 1!,f M N F PL, EXISTING ROOF COVERING
(� y�
PHONE — J — O `J NUMBER OFEXISTING COVERINGS �N(J
CONTRACTOR'S
NAME v`3 .9- �00�1 TO BE REMOVED D N TO BE RETAINED 1Ll•�
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP Io S `� '�A U 1bTt9 GU4(�kT-I i. of
EXISTING
PHONE �'O$— 2 S�+Z — Z BUILT-UP ROOFLICENSE
❑
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES w
7000)of Division 3 of the Business and Professions Code,and my license is In full force and
effect.
WOOD SHINGLES
License Cleea �C Lic.Number '7_511>5G
� '7_511>5 Q
Date R^ 24 1 Contractor �x'4 , R'IsPA N OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,altar,Improve,demollah.or repair any structure,prior to its Issuance,also requires the BUILT-UP ROOF
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 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($500).):
C]1,as owner of the property,or my employees with wages as their sole compensation,wl1i do WOOD SHAKES ❑
the work,-end the structure Is not Intended or offered for sale(Sec.7044,Business and Prafea-
alonsCode:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.ll,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER (SPECIFY) ❑
not build or Improve for purpose of sale,).
❑I,as owner of the property,am exclusive contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
[:]I am exempt under Sec. ,B&P.C.for this reason
Owner Date AP ION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: /�
❑I have and will maintain a Certificate of Consent to esi-Insure for Worker's Compensation, �j (, sp g Building r/. L 7 .
as provided for by Section 3700 of the Labor Code,Mr the performance of the work for which this j� T I
permit$h Issued.
AUG 2 4 9980 Seismic
j La have and will the performance
Worker's Compensation wok for Insurance,as requiredsu Section 3700of's
„the Labor Coda,for the performance of the work for which this permit Is laeuatl.My Worker's
'
Compensation Insurance ca�rr`ier antl Policy number are: �q Total
Carrier ST 14�L T-U�I Policy No.12 7 695— A 8 ERMIT AUTHORIZATIO DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 •�
(This section need not be completed If the pOmll la for one hundred dollars($100)or lees.) IJm ,'{ --1O Z0
a
I certify that In Na performance of the work for which this permit Is Issued,I shall not employ r
any person In any manner so as to become Subject to the Workers'Compensation Laws of Call. All roofs shall be inspected prior to any roofing material being
fornia, installed. If a roof is installed without first obtaining an
Date&-- —� Apo lloant � inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: II,afar maks this Certificate of Exemtion ou s uId become Applicant understands and will cont
subject to the Workers'Compensation Pprov alone of the Labor Code,you r t I1h comply pP ply with all non point
with such provisions or this permit shal the deemed revoked. SOUfCe regulations.
I cenify that I have read this application and state that the above information Is cormcl.I agree
to comply with all city and county ordinances and slate laws relating to building construction,and Of COVerin S to be Class 9 or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes. _ C�
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, (f7..� d-24—19
judgments,costa and expenses which may In any way accrue against said City In cone--------
of the granting of this permit. /SIGNATURE OF APPLIC NT DATE
PRE-INSPECTION: PLYWOOD: IN-P ESS:
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