R-6077 (2) APPLICATION FOR CITY OF CUPERTINO
PERMIT 6077
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1 B DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
lbw �� G� LANA RESIDENTIAL zw&COMMERCIAL OTHER
OWNER'S 1, HAZARDOUS FIRE AREA
daca�NAr-) I�NANG YES ❑ Ilylassem lyisredtheLaClassA
NAME 11 as
is required.
n NO [JInitial I.C.B.O.q
ADDRESS `bw2J ps112 NW(9,—rOr3 LA�� EXISTING ROOF COVERING
PHONE J r� I NUMBER OF EXISTING COVERINGS
CONTRA OR'S /� T�II')�,� //l
NAME S 0k1S5APC6 `"�`'� )�G `n - t 'N C.. TO BE REMOVED TO BE RETAINED
ADDRESS ZZ LZ Qd'(_OLN AV(r. • S.1T TYPE OF ROOF COVERING
clTv s zIP t5 � EXISTING
PHONE 44� -y��.-� BUILT-UP ROOF ❑
LICENSE S5� �(� /ic�g�.{ALT$�h�ING
NUMBER 64�/ D
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensetl under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑ -
7000)of Division 3 of the Business and Professions Cotle,and my license Is In full force and At Ir, &Q� E
effect /1 �y 615�1—'f FiYWA(J L�
License Class ` ` Lic.Number ` T'�n _ ❑
Date Z��it Contractorf&�A54SANW I�.Ooih)A I OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PR
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
construct,alter,Improve.demolish,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 9(commencing with Section 7000)of DlvlsiOO 3 of the
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
axe mption.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(S500).):
L]1, SHAKES 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(Sec.7044,Business and Protes.
slons Code:The Contractors 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.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) ❑
Oct 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 Contractor's 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 contracior(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm untler penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to salbinsure for Workers Compensation, Building
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 Worker's Compensation Insurance.as required by Section 3700 of Seismic
the bor Code,for the performance of the work for which this permit is Issued.My W rker's Total
Compensation!Insunrance carrier entl Policy number are:
Carrier /°A'1'rs �N a Policy No.6IN PERMIT AUTHORIZATION DATE
CERTIFICATE OF E%EMPTION FROM WORKERS'1 I
COMPENSATION INSURANCE NCQ2
�. O 3
(This section need not be completed it the permit Is for one hundred dollars($100)or less.) R 4 -
I 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 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,l agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become 'A licant nderstands and will com I with all non oint
subject to the Workers'Compensation provisions of the Labor Cotle,you must forthwith comply pp p y p
with such provisions or this permit shalGbe deemed revoked. Source FuV
oIcertify that I have road this application antl state that the above Information Is correct I agreeto comply with ell city antl county ordinances antl state laws relating to building construction,antl All r0 gs} be C C or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in. /9
apache)purposes. ( Z
(We)agree to esus,indemnify and keep harmless the City of Cupertino against Ilebillllea, / O
judgments,costs and expenses which may In any way accrue against said City in consequence -S-IGNATURE OF APPLICANT DATE
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY