R-6547 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R 6 5 4 7
INSPECTION DIVISION - PERMIT EXPIRATON
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
•-. BUILDING ADDRESS r-oo1 '
1 j 4 RESIDENTIAL COMMERCIAL OTHER
OWNER'S - - HAZARDOUS FIRE AREA
YES ❑ If yes-I oder fend theta ClawA
NAME 1 �l .(1 V 1 `V W, V l �. U 1 �. 1 r I A A roof rmEly is reglired
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No ❑ Initial I.C.B.O.f
ADDRESS�I U IZA I A Ljs LLLe2 EXISTING ROOF COVERING
PHONE //11 — .J �/ Loo
NUMBER OF EXISTING COVERINGSCONTO
NAMER�C�i A it ��(II ILo l � y L�
-TO BE REMOVED _TO BE RETAINED I
ADDRESS / �/ `fes/ I ^ ' ` \ Q TYPE OF ROOF COVERING
CITY B ZIP . e.rl lel )Li✓ 1' uiliV .
,'II,.,/� /J EXISTING
PHONE �I/ll'D L4 L L/ BUILT-UP ROOF ❑
LICENSE
NUMBER Z ASPHALT SHINGLES ❑ //
LICENSED CONTRACTORS DECLARATION(c
I hereby affirm that I em licensed sutler provLsione of Chapter a(cammendng with Section � WOOD SHAKES '
7000)W DMsion 3 of the Business and Prolessons Cade,and my
keenea is In ffIullnnforce and -
LieffiegL.Cla toZ w WOOD SHINGLES
License Close Lk.Number ❑
�(� OTHER (SPECIFY) ❑
Date ContConimctor - `J
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm met 1 am exempt from me Conbenors License Lew for the following neem.
(Sec.7031.5,Business,and Profeestooe 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 penult to file a signed statement that he Is licensee pursuant to the provisions
-
of the Contractor's License Lew(Chapter a(commends,with Sadbn 70001 of Division 3 of the -
Business anc Professions Cods)or that he is exempt therefrom and the basis for alleged ASPHALT SHINGLES ❑
exemption.Any vlaletlon of Section 7031.5 by any applicant for a permit subjects the applicant to
a cMI penally of not more than five hundred dollars
E]1.as owner of the property,or try employees with"gee as Moir We compensation,will W WOOD SHAKES
the work,and the structure Is rot Intended or offered for sale(Sec.70" Rumness and Proles-
elons Cade:The Contractors License Law,does rot appy to an owner of property who Iwnda or
Improves thereon,ark who does such work himself or through his own employeed mWOOD SHINGLESs,provided ❑
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is saki MINI we year of completion,the oener-bullder will have the burtlm of pram,that he tib OTHER(SPECIFY) ❑
not build or Improve for purpose of eels.). -
I,as owner of the property,am exclusively contracting with Ibensec contradws to construct -
the project(Sec.lona,Business and Proleasions Code:The Contractors License raw does not PROVIDE I.C.B.O.REPORT NO.
only to an owner of property who bulkis or Improves thereon,and who contract for such projects ,
with a contractor(s)licensee pursuant o the Contractors Ucenea Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for the real
Owner Date APPLICATION DATE VALUATION PERMIT FEE !
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury me of the tdiowing declaration:
1 hese and will maintain a Garb icate of Consent m sell-Insure for Workers Compensation, /1 ///11L,, / n/I/^/ Building Y /
as,provided for by Sectlw 37011 o1 theLMor Code,for me pedwmance of the work for which this I I I' toto O
per Itul 1,/y _I J W
ve and will maintain Worker's Compensation Insurance,as required by Smdon 3700 of Seismic
the Cade,for the performance of the work 1 which this ps rmlf le Issued.My Workers
Compact Ion I eumnc center Mtl-Policy nunWer re: - Total(�
Carrier PdicyNo. 7M94541
PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE N.0
(This eecibn need rot be completed 1 the permit Is for one hundred dollars(f 100)or leas.)
I certlty dust In the perlormance of the work for which this permit Is Issued,I Mall rot employ
anry person In any manner so as to become sub to the Workers'Compensation Laws o Cell- All roof^shall be inspected prior to any roofing material being
lonw. /, p ,�y� nstalled. If a roof is installed without first obtaining an
Date r� Applicant _ `^ Cit/L 1nspeciion,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you Moub became Applicant understands and WIII'coon I with all non Int
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P Y Po
with auch provisions or Ihla permit all deemed revoked. Source regulations. r
I cermy that I have read We application and state mat the above Information Is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and r AtIf Coverings to be class'46rbetter.
hereby author"representatives of this city to enter upon the above-mantomd property for In.
spectlon purposes. -
(We)agree to save,Indemnity and keep harmless the Oty of Cupertino against IlablNtiee, I
illtlpmenta,costs and expenses witch may In any way ecce against said Cly In coneauryaroe
of the granting of this permit. SIGNATURE OF APPLICANT DATE
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