R-650740
•
APPLICATION FOR
REROOF PERMIT
11LDING ADDRESS,., C to too Wayv�
V
OWNER'S
NAME _
1 CC
CITY OF CUPERTINO
INSPECTION DIVISION
(408)777-3228
CONTRACTOR'S' /n�
NAME M(CL l 02rU1 W1(.t 4 XC7J VSA .
ADDRESS 2_
PHONE
I hereby affirm that I am licensed under provlskxu of Chapter 9 (commencln9 with Section
7000) of OMelon 3 of the Business and Professlons Code, and my license Is In full bice and
effect.
U...0;Uc. Number
Data `�"-� / 'Comli
OWNER-BUILDERD CIARATION
I hereby at that I am exempt from the Contractor's Ucanse Law for the hollowing reason.
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
carts r , after, Improve, dan ollsh, or repair any structure, prior to Its Issuance, also requires the
applicant lar such permit to he a algne t statement Nat he Is licensed pursuant to Me prwlalons
of Me Convector's Ucensa law (Chapter B (comarenclig with Section 7000) of DMalon 3 of the .
Business and Professions Code) or Met he Is exanpt therefrom and the bests for Me staged
exemption. Any violation of Section 7031.5 by any applicant for a permit subjaca Me applicant to
a civil Penalty of not more than five hundred dollars (8500).):
❑ 1, an owner of the property, or my emp"s with wages as Meir sde compensation, will do
Me work, and the structure Ie not Intended or offered for sale (Sec. 70N, Business and Profen.
sbns Code: The Cantredoes License Law does not apply to an owner of property who builds or
Impmias Manan, and who does such work himself or through his awn employees, prodded Mat
such Improvements aro riot Intended or offered for sale. If, howrnmr, Me Wlldlrg or Improvement
is said within one year of completion, the owner -builder Mg have the burden at proAng that he tlW
not build or Improve for purpose of sale.).
❑ 1, as owner of the property, am excluslvety, contracting with Ilceroed contractors to construct
the project (Sec. 7044, Business and Professions Code: The Contractors License Law dose not
apply to an owner of property who builds or Improves thereon, and who contracts for such projacta
wilh a contractor(s) licensed pursuant to the ConVactor's Ucense Law.
❑ I am exempt under Sec. ,B IS P. C. for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penafty, of perjury one of the following declaration:
❑ 1 have and will maintain a Certificate of Coment to sell -Insure for Worker's Compensation,
as pmv{ded br by Section 37W of the Labor Coda, for Me periwmence of the work for which me
permit Is Issued.
❑ I have and will maintain Worker's Compensation Insurance. u required by Section 3700 of
_the Labor Code, for the ponorol of the work for which dale Permit Is Issued. My Worker's
Compensation Insumi carrier and Policy number ere:
Caroler 1-�w lOV1 gl / n C< PLCO Policy No. We -z- Ot I �SZ S
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NG.I]
(This secllm need trot be completed If Me permit is for one hundred dollars ($1 DO) or lase.)
I ceriHy Mat In Me performance of Me work for which MIs psrmfl is lesued. I shall rot skoy
any porton In any manner so as to become subject to Me Workers' Comtlon Lowe of C II-
torole..
Date - .Appllcant
, NOTICE TO APPLICANT: If, after making this Certfffcete of Exemption, you should become
subject to the Workers' Compensation prwlsions of the Labor Code, you must forthwith comply
with such provisions or this permit ehalgbe deemed revoked.
I certdy that I hews read dais application aria tate Mat Me above Information 1s corneal. I agree
to comply with ek dry arW county ordinances entl Bute laws relating to building construction, and
hereby authorize rePmaenufirms of this city to enter upon Me abc+ mmnlonatl property for In..
to save, Indemnlfy and keep harmless the City of Cupervno against Iladlkles,
'.s and expenses which may In any way accrue against said City in consequence
11 this permit.
PRE -INSPECTION: I PLYWOOD:
INSP. DATE
TEAR OFF INSPECTION:
RESIDENTIAL '?('\
NUMBIERR- 6507
PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1W DAYS FROM LAST CALLED INSPECTION.
OTHER
YES ❑ H yes - I understand tial a Close A
rod a nnfxly is required.
NO F1 I Intim I.C.B.O. R
NUMBER OF EXISTING COVERINGS
0
TO BE RETAINED
TYPE OF ROOF COVERING'
EXISTING
BUILT-UP ROOF ❑
ASPHALT SHINGLES ❑
WOOD SHAKES
WOOD SHINGLES
OTHER (SPECIFY)
PROPOSED I-; MAY p 7
BUILT-UP ROOF 1999
BUILT-UP
ASPHALT SHINGLIzS3%t Cf
WOOD SHAKES
WOOD SHINGLES ❑
OTHER (SPECIFY) ❑
PROVIDE MFGR. INSTALLATION SPECS.
PERMIT FEE
Building <-o
7 7� Seismic-�� ^,lR6
e
Total t�L1!
I PERMIT AUTHORIZATION I ..DATE . I
t� 13--0 g t
All roofs shall be inspected prior to any roofing material being
installed. If a roof is installed without first obtaining an
inspection, I agree to remove all new materials for inspection.
Applicant understands and will comply with all non point
source regulations.
All roof coverings to be class 6or better. be
SIGNATURE OF APPLICANT DATE
IN -PROGRESS:
919TAli
NOTE:' OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION