R 6259 (2) PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 6259
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.
BUILDINGADDRESS
Og3S
RESIDENTIAL e's COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME
N 1'1 G H r-1/-i L Ci-F+
YES
rg 'root assembly Is faqul e1 a Gla-5 .
NO ❑ - Initial I.C.0.0.q
ADDRESS )0�SS V`''I U WV)f�,?Q)f( COVERING
uV 1+1-4 EXISTING ROOF
PHONE 7 2 S '� G r, NUMBER OF EXISTING COVERINGS / W
CONTRACTOR'S -
NAME t"IP iZJu�I N 6 '1C ��NS TO BE REMOVED � TO BE RETAINED
ADDRESS /, I ''� S TYPE OF ROOF COVERING
CITY 8 ZIP`t'1'
EXISTING
PHONE 40& 2�Z- �u31 Z.- �SI'� BUILT-UP ROOF ❑ .
LICENSE 22 `
NUMBER J 7 v ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that em Business
under Professions
of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 a the Business end under
provisions
Dote,and r 9 license le In lull tome and
WOOD SHINGLES ❑
License Class Us.Number
t
CI
Date - Contractor OWNER-BUILDER DECLARATIONBhereby affirm Ihel I am exempt Iro s the Contractor's License Lew for the following reason.
(Sac.uct alt Buslnese end Profeolish,or rep Cotle: Any city or county which requlree a permit to }(� 5 1998construct,alter.Improve,tlemollsh,or repair any structure,prior to Its issuance,also requlree the a 0applicantfor such permit to file a signed statement that he le licensed pursuant to the provisionsof the Contractor's License Lew(Chapter 0(commencing with Section 7000)al Dlvlslon 3 of IhaBuslnese entl Profoeslene Cotle)or that he is exempt lherafrom entl the basis for the ellegetl INGLES -
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($50th),):
❑I,es 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 Proles-
alone Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES EJ
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) El
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 contractors)licensed pursuant to the Contractor's License Law.
CI PROVIDE MFGR. INSTALLATION SPECS.
I am exempt under Sac. ,B&R C.(or this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
E]I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building/.2 as provided or by Section 3700 of the Labor Code,for the performance of the work for which this 7'1
permit is Issued. 1400 Seismic
have entl will maintain Worker's Compensation Insurance,as required by Section 3700 01
the ober Cotle,for the performance of the work for which this permit la issuetl,My Workers
'Compensation Insurance carrier and Policy number are: f Total 12 7 , d z
carrier-S? PE IS N() Policy No. I Z�s✓Sf_Jf? PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NAS
(This section need not be completed II the permit la for one hundred tonere($100)or lessJ L/�J
1 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 Call- All roofs shall be inspected prior to any roofing material being
farms. !� f installed. If a roof is installed without first obtaining an
Date /i-- (/2 Applicant Gx4 �-�^� �_ inspection,I agree to remove all new materials for inspection.
NOT CE TO subject to the Workers'Compef,afternsation prowMYfielonls of thei'cate of Laborr Code,Exemption,m pus hiv th comply Applicant understands and will comply with all non point
with such provisions or this permit shalfbe deemed revoked. $OUTCe regulations.
I certify that I have read this application and State that the above Information is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All ro I coverings to b class"6r
6 r better.
hereby authorize representatives of this city to enter upon the above-mentioned property or In-
spection purposes.
(We)agree to Save,Indemnify and keep harmless the City of Cupertino against Ilabllitiea,
judgments,coats and expenses which may In any way accrue against said City In consequence
•
of the granting of this permit. AGNATARE—OF APPLI AN DATE
PRE-INSPECTION: PLYWOOD: IN-PROGR S:
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