R 6171 (2) APPLICATION FOR CITY OF CUPERTINO
Nu sl R R- 6171 .
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-9228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM UST CALLED INSPECTION.
BUILDINGAD/DRESS 1 '
O bL ^y10 V l5 C , RESIDENTIAL COMMERCIAL OTHER
OWNERS HAZARDOUS FIRE AREA
NAME 'e.Y� KI�SI /\ VES ❑ royes sembly U
nderstand
required ClassA -
roof assembly Is required.
NO ❑ Initial LC.B.O.#
ADDRESS EXISTING ROOF COVERING
PHONE Q— q 61 al NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME O S TO BE REMOVED / TO BE RETAINED
ADDRESSTYPE OF ROOF COVERING
CITY&ZIP 14"k 6LI - aq)? QLY_ �vhrLVye. �A�'
EXISTING
PHONE P00-737 Q-56 BUILT-UP ROOF .❑.
LICENSE
NUMBER 011 ASPHALT SHINGLES El
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed 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
effect. /� WOOD SHINGLES ❑ C
License Clava Lt_ Lic.Number u V l?�
Date �01�g� Contractor � & OTHER(SPECIFY) ❑
OWNER-the Conn DECLARATION PROPOSED
27,
hereby affirm that I am exempt from s the Contractor's or roue Law for the followingpermit
treason.
(Sec.7031.5,,Improve and Professions it any Any city or county which requires also a permit to
applicant,alter,Improve,demolish,signed
kementrtat he prior tole Issuance,to the
atBUILT-UP ROOF ❑
at the
applicant for such permit a flaw a signed statement inch he is licensed pursuant to the provisionsth
of the ss and
License Law)lChapterthat h is ex a pt tp with Section 7000)of Division 3 of the
• Business end violation of Code)or that he le exempt ant or a and the bash for the alleged ASPHALT HALT
a civil en.Anyviolationof onofhan lin hundred
byany applicantfor apermit subjects the applicant to
a civil penalty of not more than Ilva huntlretl dollars($500).):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do W SHf�
the work,and the structure Is not Intended or offered for mate(Sec.7044,Business and Protea.
slonc Code:The,and who
License Lew does s not apply to an owner of property who bunds or WD $I�(p(GLF,,S 1998
Int thereon,and who dews such work himself or through his own employees,provided s or uG I U
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTI P1�WtX:>
not bulld or Improve for purpose of sale.).
❑a,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PRI I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractogs)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.•IN$TALLATICN SPECS.
❑1 am exempt under Sec. ,B$P.C.for this reason
Owner oats
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the fonowing declaration: -
C] % 7
I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building
- _
all provided for by Section 3700 of the labor Code,for the performance of the work for which this 12-0, ^
permit is Issued.
a andPQO Seismic
'L have and will maithe performance
Worker's Compensation the work
Insurance,as required is u Section 3700 s
the ober Cade,for the pedormance of the work for which ire permit a issued.My Workefe /
Compensdranceg rler andfllcy number are: Total / Op
4-0e
Carriera ronwNoIAU3 !!
PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.DO
(This section need not be completed If the permit Is for one hundred dollars($100)or IaaeJO ��
I certify that on the performance of the work for which this permit Is Issued,I shall not employ 11 —
any person In any manner eo ars to become abject to the Workere'Compensation I.awe of can- All roots shall be inspected 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.
subject to the Workers'CompeO APPLICANT: nsatlan proviafter sions oftheocate L bol Code,Exemption,
mustuforthwlltlhbecome
comply Applicant understands and will comply with all non point
with such provisions or this permit shalCbe deemed revoked source regulations.
I certify that I have read this application and state that the above Information Is correct.)agree
to comply with all city and county ordinances and stale taws relating to building construction,and All roof coverings to be class° rbetter.
hereby authorize representatives of this city to anter upon the above-mentioned property for In.
jud(We)ction purposes.
(We)agree to cave,expenses
and keep nay a y the Clry of Cupertino against liabilities.
judgments,core and expenses which may In any way accrue against said City In consequence• SIG TUBE 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY