R-6472FICE COPY
PERMIT R_ 6472
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION. DI VISION PERMIT EXPIRATION
REROOF PERMIT (408)]77-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 190 DAYS OF PERMIT ISSUANCE OR
190 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS (C,���,r� -b /�JJW
"^�"lY Y �rhW
`
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARQOUS FIRE AIR
`�
��\ �1
Ithat ClassA
YES ❑ Ryes—embly
NAME W�� -T�IIi rrll
is requiredtand
, /roof assembly a required. .
NO (�y Initial_ LC.B.O.%
EXISTING ROOF COVERING
�I �Q�{ SI
ADDRESS I�' j�o (i�C •.
6 7v
NUMBER OF EXISTING COVERINGS /
PHONE v `
TOBE REMOVED TO BE RETAINED
CONTRACTO/�$,(�-�^
C'ot�NIA I��F1MI GOr AVL,
NAME_ — VFY4I
ADDRESS
CITY B ZIP-1S/L5r JGIa VI' 5�\0� cp-9512EXISTING
TYPE OF ROOF COVERING
BUILT-UP ROOF - D
..n
PHONE40 a"I3 7-7
LICENSE
NUMBER
Lid Q�
I
ASPHALT SHINGLES AFIR 16 �ggg
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
WOOD SHAKES ❑
701X)) of Division 3 of the Business and Professions Code, and my license U In lull force and
effect
BY
4 O
WOOD SHINGLES
License Class_,.� =J-- Lic. Number
,�j���
�� I (0
OTHER (SPECIFY) ❑
Data Con aaorrAri-C wyn �
' OWNER-BUILDERDECIARATION
I hereby affirm that I em exempt from the Contrsctora Ucense Law for the bllowlnp reason.
7031.5, Business Professions Code: Any dry
PROPOSED
(Sec. and or county which requires a permit to
construct,after, Improve, demollsh, or repair my structure, prior to its issuance,s th
also refulree
I /
BUILT-UP ROOF
it"Unt for Much permit to file a signed statement that he Is licensed pursuant to the provisil
a the Contractors License Law (Chapter 9 (commencing with Sectlon 7000) of DMsion 3 of the
Business and Professions Code) or Met he is exempt therefrom aro the balls for the Mingo
ASPHALT SHINGLES ❑
exemption, Any violation of Section 7031.5 by any applicant for a permit subjsole the applicant to
-
e dyll penally of rot more than five hurWred dollars ($500).):
WOOD .SHAKES ❑
will s-
❑I,es owner ofthe property, tImyemployees red wegee as their sole Iompessa and
Me work, and the structure Is not Intended or for (Sec. ]044, antl Pros
West ofproperty whowilesor
slpnoCode: The Contractor's License Lew doesnot apply to property or
WOOD SHINGLES ❑ '
or through
Improves thereon, and who open such work himself or through hie awn employees, provbetl Met
his
Busted are not Intended or offered bort leer. If, however, the or
arv, ye iImprovement
en of pr
within owner -builder will have Ura wrtlen of proving Net he ®d
issoldbuildhlnor»vvifor cnnpla
OTHER (SPECIFY) ❑
of sthe
not wild or Urprove for purpose al sale.).
❑ I, as owner of the property, am exclusively contracting with icensed contractors to construct
the protea (Sec. 7044, Burliness and Professions Code: The Contractors Ucenae Law does not
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who wilds or Improves thereon, and who contracts for such projects
with a contractor(s) licensed pursuant to the Contractors Lienee Law.
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 am exempt under Sec. .B & P. C. for this reason
Owner _ Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penelty of perjury one of the following declaration:
[:11 he" and will maintain a Certlficate of Consent to seH Insure for Workers Compensation,
as provided for by Section 37W of the Labor Code, for the performance of the work for which this
permit sound.
/�
�I 7, o
Building
$eISmIC d
hove and will maintain Workers Insurance,hthis as required by Section 3]00's
,��v— I_f
V
���///111
f One w rkhu
the loom Code, for the perbrmence of cy work a wNU this permit B issued. My Workers
Campensedon In ure�nc/e certbr emit Policy number are:
_03
Total
PERMIT AUPICIfflIZATICIN
DATE
Comer `-'T+c~ �Pdlcy No,I5�705
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NCj]
�G
n need rrot be completed e permit Is for one hundred dollars ($100) or lees.)
(This sectioH th
�i'/C�
4
I certify Mat In the performance of the work for which MIs permit is insued, I shall not employ
any person In any manner so as to become subjecl to the Workers' Compensation Laws of Cell-
All roofs shall be' spected prior to any roofing material being
lona.
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 certificate of Exemption, you should become
subject to the Workers' Compensation provislom of Me Labor Code, you must fortl comply,
Applicant understands and WIII comply with all n00 point
pP P Y P
with such provisions or this per tt shall be deemed revoked.
Source regulations.
I certify that I have react this application and state that the above Information Is correct. ) agree
• to comply with all dry and county omlrranoes and state laws raletlng to wilding conewWan,antl
All rO OV Brings to be Cl O tier.
hereby authorizePurprepresentatives of this dry to anter upon Me above mentbnetl property for In-spectio
hereby Purposes. '
IWM agree to save, Indemnify and I harmless the Cly of Cupertino apalnsl Ilebllitles,
!
jutlgmenta, coat" era expenses which may In arry way accrue against seal Olry In consequeroe
SIGNATURE AP LICA DATE
of the ting of tis permt.
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
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