R-6389 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R-
6389
INSPECTION DIVISION. . PERMITEXPIRATION .
'REROOF PERMIT (408)777-32213 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS -
uq (J
RESIDENTIAL COMMERCIAL OTHER-
OWNER'S
THER
OWNER'S(/^� [/1understand
HAZARDOUS FIRE AREA
. NAME v j L e � t Pe� �' S 44 •' YES ❑ fyes�I uta� It�t a Chase A
NO Initial LC.B.O.11
ADDRESS�7r 30 f7e' 5_T ✓ 4 � •� � -0 -^� EXISTING ROOFCOVERING
PHONE - NUMBER OF EXISTING COVERINGS
CONTRACT TO
' - 1 r --cf—
NAME ` 0 L-1S W TO BE REMOVED TO BE RETAINED
ADDRESSg' �, LZ , ✓� o Ip ( TYPE OF ROOF COVERING
CITY 6 ZIP 7 `T U
EXISTING .
PHONE y o ` �7 y (o .2 Z y BUILT-UP ROOF ❑
LICENSE
NUMBER - ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby effkm Het I em licensed under provisions of.Chapter B(commencing with Section WOOD SHAKES
7000)of DWslon 3 of the.Business and Professions Code,entl my license is in full force end
effect.
(� 3 5 y 3o l WOOD SHINGLES ❑
Ucanm Close `•"- � Dc.Number
Date 3 2 Connector �G u`c bco�B OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED.
hereby affirm that I em exampl from the Contractor's License Law for the allowing reason.
(Sec.7031.5,Business and Professions Code: Anor county wNch requires a permit to
wnetruct,Mar.Improve,demolish,orrepeb any structure,prior to its Issuance,also requires the BUILT-UP ROOF E,applkant for such permit b file a signed ntatement Mat he is licensed pursuant to the provlsic ra
of the Contractor'.LicenseLew(Chapter g(commencing with Section 7000)of Dhisicn 3 of Me
Business and Professional Code)or that ha la exempt therefrom end the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit ' I (cent to
e chit perrelly of not more thin Nva hundred dollars(5500).):
❑I,as wmar of the property,or my employees with wages as their I pe�do JROVIDE
OOD SHAKES ❑
the work,end the structure le not Intended or offered for Bele(Sec.7 sines es-
alone Cade:The Contractors License Law does not apply to an owns arty who bul or OD SHINGLESImproves Hereon,end who dare each work hYmed or through his oyaee,provided Met ❑such Improvements are not Intended or offered for We.It,however IIdin pro%r�wt Is sold within one year of completion,the ownerbullder will have the an of T=1d (] HER(SPECIFY)not build w Improv for purpose of sale.). 1x79❑I,es owner of the property,em exclusivey contracting with lice contractors to construct
the project(Sec.70",Suelneee end Prolaakns Cade:The Contr icon"Lew does notOVIDE I.C.B.O.REPORT NO.
apply to en owner of property who bulks or lmprovesthereon,and reach projects
with a contmctw(s)licensed pursuant to the Contractors Ucanm Law MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,B 6 P.C.for this re
owner ' Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
'
I hereby affirm under penalty of perjury one of Me lollowing dedaratlon:
❑I hove and will maintain a Certlficate of Consent to sail-insure for Workers Companmtion, Building 2- 7
as provided for by Section 3700 of the Labor Code,for the pert rmarce of the work for which this
permit is Issued. /y3
❑1 have end will mailmen Workers Compensation Insurance,as required by Section 3700 of // O"� Seismic
IPD
_the Labor Code,for the performance of Me work for which this permit Is Issued.My Workersy/
Compensation Ineu cerrbr end Pdioy nu`` err are: TOtal /� •e7
�'O
Carrier Sr4c '^ T Pdks•No. Z' PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.Cj] �y
(This section need trot be completed 1 the permit is fon one hundred dollars(5100)w lase.) �� Y
I ceriHy,that in the pen camence of the wank for which this permit Is issued,1 shall not emptaY
any person In any manner w as to become su act to the Wr'.,Compenmibn Lawn d Calc All roofs shall be inspected prior to any roofing material bOing
fornia. installed. If a roof is installed without first obtaining an
Date y a G Applicant - inspection,I agree to remove all new materials for inspection.
NOTICE TO APPUCAIIT: If,after making this Certificate of Exemption,you should become applicant understands and will comply with all non pain[
subject to the Workers'Cormponmtfon ovialons of the Labor Code,you moat WhMM complywith such provislone or this permit shelO be doomed retoked. source regulations.
I certhy that I have read this application and state that the abova Inlsrmatlon 1.correct I agree
to compy with all city and county ordinances and state lave relating to building construction,end All roof coverings to be class' or better.
hereby authorize repro umurfvm of this city to enter upon Me abave-mentloned property for In-
spectlan purposes. .
(We)agree to rove,Indemnity,and keep harmless He Cly of CupertI ro against IIebIlNiee,
judgments,costs and expenses which may In any way accrue against said City In consequence
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