R-5618 (2) PERMIT R_ 5 618 .
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
7- 6093 Ltd 1-ffi&A--i 0AJ V Qi RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
/� VES ❑ If yes-I understand that a Class A
NAME / •A,Y /"M ERS roof assembly is required
.t/ \ NO Initial I.C.B.O.a
ADDRESS Z �3 V r�'�A'roN V R. EXISTING ROOF COVERING
PHONE *2 5-3 — 5 C.(Z NUMBER OF EXISTING COVERINGS l
CONTRAC'TAOR'S
NAME -4LI- To 4S OsA;S R0,& 4^J6 _LNC, TO BE REMOVED }tent MOVw_-� TO BE RETAINED
ADDRESSTYPE OF ROOF COVERING
CITY BZIP3 9 y 41m s4,ic%A4 EXISTING
PHONE ) ?17- BUILT-UP ROOF - ❑
LICENSE
NUMBER /3 00 / ASPHALT SHINGLES ❑
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 full force and
effect.
WOOD SHINGLES
License Class C Lia Number 5 3 60/ I� `
Data !o /`� 4� Contractor $KtAC4 y61&St-0EK OTHER(SPECIFY) 7
OWNER-BUILDER DECLARATION PROPOSED sb��
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 C/ ED 10
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions S
or the Contractors License Lew(Chapter 9(commencing with Section 7000)of DIVislon 3 of to dA
• Business and Professions Code)or that he Is exempt therefrom and the basis for rho alleged ASPHALT SHINGL @`
exemption.Any violation o1 Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).): WOOD 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 Profen-
sions III,
The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES fLFI
Improves thereon,antl 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-bulltler 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,em 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 contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B It P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-insure for Workers Compensation, pp Building
97
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /p�/!{/ "f73 Z7 CT
permit is Issued. !!! Seismic
1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit is Issued.My Workers -'7- Total
Compensation Insurance carrier and Policy number are:
Carrier RAll 81 C 1:N0FMAJ11YCs olicyNo.I z g37V01 PERMIT AUTHORIZATION DATE
OA A A'k'4IfLtuS`CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the permit Is for one hundred dollars($100)or lees.)
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'Compensatio awe or can- All roofs shall be inspected Priorto any roofing ma eria being
fornia. installed. If a roof is installed without first obtaining an
Data IVX5�A 7 Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO
posExemption you
become
subject to eWorrkersComponsatlon provisions of the Labor Code,you mstforthwithcomply Applicant understands and will comply with all non point
with such provisions or this permit shall be 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 state laws relating to building construction,and All roof coverings to be class ' "or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
ap(We) purposes. �eW,� r a�4 7
(uta)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costa and expenses which may in any way accrue against said City In consequence SIGNATUREOF APPLICANTDTE
• of the granting of this Permit.
PRE-INSPECTION: PLYWOOD: / IN-PROGRESS:
INSP. DATE - INSP. DATE /G /7`97 INSP. DATE < < 7
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE /14 7 INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY -