R-6516 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R 651
6
INSPECTION DIVISION ERM xPt n N
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 -7 t �p-(yN, D S. 10(.DO
�� r 2l Z I / V • RESIDENTIAL COMMERCIAL - OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ n yes-I understand that a Class A
NAME r'Tt/`�1/"A a ewe rod assembly is required.
y� L �� / q NO ❑ Imbed- I.C.B.O.C
ADDRESS I.Sy Q�r-r t✓7rJ --1� �"b`I'b� VtLA�J EXISTING ROOF COVERING
PHONE b 11(l9 30 NUMBER OF EXISTING COVERINGS
CONTRACT 'S TO BE REMOVED TO BE RETAINED- OLS_`SLS O
ADDRESS3g61 ,� (7 TYPE OF ROOF COVERING
CITY aZIP l7 EXISTING
PHONE Cyv�/ 3BUILT-UP ROOF ❑
LICENSE Z-2 -73) ASPHALT SHINGLES ❑
NUMBER
UCENSED CONTRACTORS DEC1ARI
I hereby pmmn that I am licensed under provi;fons of Chapter a(commencing with Section ODD SHAKES
7000)of Division 3 of the Buslneee ark Professions Code,ark my,license b In full force and
eneL"' �/ 7 WOOD SHINGLES
License Class. _ Ul No or '`2Z r 7 ER(SPECIFY) D
—x`99
Dale OWNER-B! 'I IER DEC ATION MAY 141999
I hereby affirm that I em exempt from Me Contractors Ucense Law for Ne following reason.
(Sec.7031.5,Business and Professions Cada: Any city or wanly which requires a permit to
construct,alter,improve,demollsh,or repair anywructure, rbr(o pe lswarrw,slw requires the BUILT-UP R OF ❑
applicant for such permit to file a signed statement that he Pa licensed pursuant to the prodsions By
of Me Contractor's License Law(Chapter B(commencina with Section 7000)of Dlvicon 3 of the
f Business ark Professions Code)or Met he Is exempt therefrom"Me basis for the alleged ASPHALT SHINGLES
emmption.Any violation of SocUon 7031.5 by any applicant for a parmit subjects the applicant to
a civil penalty of not more than We hundred dollen(5500).):
❑I,as owner of the property,or my employees with wages ae their sole compensation,will do WOOD SHAKES ❑
the work and the itmcture is not Intended or offered for sale(Sec.704x,Buelneee arra Proles-
Mons Code:The Contractors Ucenae Lew does not sppy ho to an owner of property wbunds or WOOD SHINGLES ❑
Improve;thereon,and who does such work himself or through his own vWed employees,prothat
Much Improvements are not Intended or offered for eels.If,however,the building or Improronsnt
I.add within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or enprove for purpose of sale.).
❑I,m Amer of the property,em etcfusWy contreciwith licerl contractors to construct
the project(Sec.7044.Business and Professions Code:The Contracices 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 projecle
with a contractor(s)licensed pursuant to the Conbamora License Law. PROVIDE I INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the lollowirig deckretlon: /��. W
I have and will mrntam sen
a Certificate of Consent to -Insure for Workers Compensation. Building
as provided for by Section 37M of the Labor Code,for Me performance of Me work for which thle
permit Is Issued. �'y �e Za
❑ M I have awill malntaln Workers Componeetbn Insurance,ae required by Section 3700 of 17 15GO seismic
the Labor Code,for the pedomtence of the work for which this permit la Issued.My WorkersG
60
Compensation IInalunrcs carrier and Policy number ere: a 11/ f Total OO
Carrier �+g I]0" Policy No.Dif 2-d7-9 'j PERMIT AUTHORIZATION DATE
CEFnFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NCQ
(This aection need not be completed If the permit Is for we hundred dollars(5100)or Ins.)
I certify that In the performance of the work for which this permit is Issued.I Map rqt fol
any person In ary manner so m to beconw subject to the Wwiotre'Compen canon Laws of�eII- All moo s Siff-all be inspected prior to any roofing material be' g
fornia. installed. If a roof is installed without first obtaining an
Date -Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Cenif tate of Exemption,you Mould become A hcant understands and will Comply with all non int
subject to the Workers'Compensation provlslons of Me Labor Cade,you must forthwith comply pP P y
with such provisions or thin permit shell be deemed revoked. Source regulations.
I cattily that I he"read this appllcetlon and state Chet the above Information is carred.I agree
to comply wIth all city and county ordinances and state laws relating to building construction,and All roof Coverings to be class'C'or better.
hereby authorize representatives of Mie city to enter upon the above mentioned property for In.
spectlon purposes. ..S p
(We)agree to save,kkemnlfy and keep harmless the City of Cuperhm apelnst liabilities, c` l
I menta,sew and expenses which may In any way accrue agenel said City In consequence SIGNATU OF APP ICANT DAT-
cl the granting of Mw 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