R-6718 PERMIT6 718
APPLICATION FOR CITY OF CUPERTINO. NUMBER R"
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(8-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
1`/./-� WITHIN S F DAYS S PERMIT ISSUANCE OR
(-V� WITHIN 1 FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS 24
A, ) 26
i- RI4 27AZI RESIDENTIAL COMMERCIAL OTHER
OWNER.'/uS� / �-10 1 i4 /p/ O HAZARDOUS FIRE AREA
NAME , 1yer&A GT- All YES ❑ � IIWy is req Mata ClassA
mWy u required.
NO ❑ Initial LC.B.O.tl
EXISTING ROOF COVERING
ADDRESS /�� �L�(2 n/Q / •/T V fE.� /moi i
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
_I
NAME O l o�. TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY 8 ZIP 3P7 VD,
R7VD, i. mbi it EXISTING
PHONE 'TSD JGZ,LII BUILT-UP ROOF . ❑
LICENSE 62Z7,31 ,
ASPHALT SHINGLES
NUMBER
LICENSED CONTRACTORS DECI-AAATION
I hereby affirm that I em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES -
70W)d Division 3 of the Buslneas and Professions Code,and my Ilcense Is In full force and
erred. r/ ' moi`y�.y 7 7 WOOD SHINGLES
Ucerse Clans Lk.Number `-'`�7 3 1
Date 1'�y Contractor OTHER(SPECIFY) ❑
ONNERBUILDERD CLARATION PROPOSED
I hereby affirm Met I am exempt horn the Contractors License Law for the following reason.
(Sec.7X31.5,Business and Professions Coda: Any city or county which requires a permit to
construct,alter,Improve,demolish,or repair any stmcture,prior to Itslasuence,also requires the BUILT-UP ROOF
Applicant for such permit to file a signed eMtemont that he Is licensed pursuant to Me provisions _ D '
of the Contractor's License Law(Chapter 8(commencing with Section 7000)of Division 3 of the )
Business erne Professions Code)or that he is exempt therefrom And the hails for the alleged ASPHALT SHINGLES I!
• exemption,Any violation of Sectlon 7031.5 by any applicant for a permit subjects the applicant to
a civil pendty of not more than five hundred dollars(S5W).): I j
❑I,as Owner of the property,or my employees with wages As their sole compensation,will WOOD SHAKES JU` 11 9 Q99 It.
the work,end Me structure is not intended or offered for sale(Sac.70",Business and Profits- 1•r L l ,
stone Chris:The Contractor's License Law does not Apply to an owner of property who Wilds or WOOD SHINGLES ❑ /
Improves thereon,and who does such work himself or through his own employees,provided that p
such Improvements are not Intended or offered for sale.If,however,Me Wilding or improvement Y
Is sdtl within one year of completion,the caner-Wilder will have the burden of proving that he did OTHER (SPECIFY)
not Wild or Improve for purpose d sale.). _
❑I,es owner of the property,em exclusively contracting with licensed contodors to construct
the project(Sec.7004,Business and Professions Cade:The Contractors License Lax does Trot PROVIDE I.C.B.O.REPORT NO.
appy to an owner of property who buNds or Improves thereon,and who contracts for each projects
with a conVador(s)Iicemed pursuant to the Contractors License Law. PROVIDE MFGR. INSTALLATION SPECS.
❑I am exempt under Sec. ,B 6 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
1 hereby alllrm under penally of perjury one of Ma lolfowing declaration: c
❑I have and will maintain a Certificate of Consent to wit-Insure for workers Ccrrpinfi n, Building5
as provided for by Smfiw 3700 of the Labor Code,for Me performance of the work for which Mie c
Permit is Issued. /0,50 C) Seismic /v /O
❑1 have and will maintain Workers Compensation Insurance,as required by Section 37X3 of
the Labor Cade,low the performance of the work for which Utls permit Is Issued.My Workers IQ
Compensation Irmnt
urance carrier and Policy number are: Total _
CanierIll 1ON PdmyNk!c_w ZgsS� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need rot W completed If Me permfl is for one hundred dollars($1 00)or less.)
1 certlty Met in Me performance of the work for which this permit is issued,I shall not employ
any person in any mender so as to bBcerne subject to Me WOIke@ m
Cempeatlon Laws of CAI- All roofs shall be inspected prior to any roofing material being
1efnld' installed. If a roof is installed without first obtaining an
Data /J7"r j Apolrant �Q✓ inspection,I agree to remove all new materials for inspection. -
NOTICE TO APPLICANT: If,aha,making MI CertlHcate of Exemption,you should become Applicant-understands and will comply with all non cirri
subject to Me Workers'Compensation provisions of Ima Labor Cade,you must bnhwith comply pP P Y P
wIM such provisions or this perr i shell W Teemed revoked. Source regulations.
I cenlfy Net I have read Mia appiicntlon And stale got the Above Information Is carred.I agree
to comply with all city and county ordinances and state laws relating to Wlliing construction,and All roof c ,nn s be classor better.
hereby amnod¢e representatives of this city to enter upon Me abovementloned property for In- - -
epectlan purposes.
(We)agree to leve,Indemnify erne keep harmless Me City of Cupertino agelnst Ilabllldes,
judgments,costs and expenses which may In any way mama against sold CIly In consequence IG URE OF APPLICANT
of Me 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