R-6564 PERMIT R_
6564 .
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRAT113N
REROOF PERMIT (408)777-3228 PEPWIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS �r'�
-2-00 a �Cc1 >< RESIDENTIAL ✓ COMMERCIAL OTHER
OWNER'SD - HAZARDOUS FIRE AREA
NAME r 4 �4 YES ❑ fl yes—I understand that a CL s A
oof assembly a required.
. - NO Indiat I.C.B.O.lf
ADDRESS ZOo4vr-. EXISTING ROOF COVERING
PHONE
2-S77- 6 3 )V NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S/ 11 -
NAME Cpn<1 5 , lea0 Gr ki - TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING.
CrTYazIIFN-L EXISTING
PHONE 3-IV- AT BUILT-UP ROOF ❑ ..
LICENSE Z-J�6SZ ASPHALTSHINGLES�
NUMBER
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Seaton WOOD SHAKES
7000)of Division 3 of Lite Business arki Pmfesslom Code,and my license IB In Mg torte and
effect.
9Z WOOD SHINGLES D
License Class G � • Lic.Number Z11"
Date s^ I/- Contractor &8kr*4- OTHER(SPECIFY) IOMY 1999
OWNER-BUILDER DECLARATION PROPOSED r'1
1 hereby affirmthat I�am exempt Iron the Contractor's license Law for We following reason.
(Sec.7031.5,Business a Profession$Code: Any dry or county which requires a permit to
construct,alter,Improve,demdieh,or repair sty structure,prior to Its issuance,oleo requires the B BUILT-UP ROOF ❑
applicant for such permit to file a stgnad statement that he Is licensed pursuant to the pelon: y
of Me Contractor's License Law(Chapter.9(corrvnendnp with Section 7000)of Division 3 of the
Business and Pmfeaelons Code(or Met he Is axempt tlemlmm and the basis for the alleged ASPHALT SHINGLES '
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects Me Applicant to
a civil penalty of not more then five hundred dollars($800).):
C-]1.as owner of the property,or my employees with well as their sale compensetbn,wW do WOOD SHAKES ❑
Me work and Me structure is not Intended or offered for sale(Seo.70",Business and Rotes-
slons Code:The Contractor's Ucense Lew does not apply to an sumer of property who build$or WOOD SHINGLES ❑
such Improvements
thereon,and who tleee such work himself or through his own em bulking
or i m roe rthat
such
Improves
haueo manus not InteMed suc a offered for fele.If,however,the bullolrg a Improvement '
is sdd whMn one year of completion,the owner-builder will have the burden of proving Mel he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am escluekvely conVactinp with licensed contractors to construct
the protea(Sac.lona,Business and Professions Code:The Contractor's Ucenee Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bunds or Improve$Ill and whim contracts for such protects
with a contractor(s)licenced pursuant to Me Conbectcr'$License law. PROVIDE MFCiR.INSTALLATION SPECS.
0I am exempt undx Sec. .B&P.C.for this res$on
Owner Date APPLICATION DATE VALUATION' PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I he"end will maintain a Certificate of Consent to self-Insure for Woro is Compensation, �.�y Building
As Provided for by Section 3700 of We Labor Code,for the perlormarne of the work for which Mb /
permit hIssued. UyV SBISmIC. ��
$1 have end will maintain Worker's Ca "satlon Insurance,of required by Sectlon 37W or'.
Labor Code,for pedormanof work ton which this permit Is Issued.My Workers
ZjO
Co
Came mpeneefion Insurance carrier and Policy
cy number ere: Total
Carder s h t' F Policy N0.2$S 'j9 poo XYS ERMIT AU RIzATI DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.[3
(This section reed not be completed 11 the permit Is for ors hundred dollars($100)or IeeaJ
I certily that In Me performance of Me work for which Mie penhit Is Issued,I shall not employ
any pmeon In any manner so as to become subject to Me Workers'Compensation Laws of Calf All roofs sh be Inspected pint or to any roofing material being
f'n'ia. �y � installed f a roof is installed without first obtaining an
s
Date -19- 17 Applicant ,Go.x- _ - inspecli ,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should became Applicant.understands and will comply with all non point
subject to Me Workers'Compensation provisions of M
e Labor Code,you must forthwith comply
with such provisions or Isis permit shell be deemed revoked. source regulations.
I certify that I have read this application and state Mat the above Inlormetlon is correct.I agree
to comply,with all dry s county ordinances and state laws relating to building corntrualon,aM All roof coo rings to be class"C'or better.
hereby aulhprepresentathes of Mie dry to enter upon the above-mentioned property for ILLQ
ape Wepurpoo a ses.
(We)spree to save,Indemnify and keep harmless the City of Cupedlrw agelnst liabilities, JJ
judgments,costs end expenses which may In Any.way Accrue against said City In con$equenu SIGNATURE OF APPLICANT DATE
of a granting of this parmk.
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