R-6406 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO . NUMBER 6406
INSPECTION DIVISIONPERMIT FXPIRAI ON
REROOF PERMIT (408)777-3228 - 'PERM IT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
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BUILDING ADDRESS ,/,(1/� I ,t,,.
LD I `V TOitki-& 1 Y.!t 1. wcN � RESIDENTIAL ' COMMERCIAL OTHER
OWNER'S //1 '/�1 ,y HAZARDOUS FIRE ARE
1 nO.V1 y7 �,/n YES 0 If yes_I tmtlerstand that a Class A
NAME roof esserldtly is required.
NO IrthW I.C.B.O.O
ADDRESS �UUQ �;py�-x. 1 � ✓r""" y `-y" I�. 'EXISTING ROOF COVERING
PHONE IQLa—" l-1 o U NUMBER OF EXISTING COVERINGS
CONTRACTOR'S y�
NAME ,L� l'. v �p�UAI,�1- ,y�,/ %31 TO BE REMOVED TO BE RETAINED
ADDRESS Io OAt—L/.1 . TL,Atl, U,7 Gkos ' 3 T�'pEOFROOFCOVERING
CITY B ZIPIDUS- 0I
PHONE �u ' ly t BUILT-UP ROOF ❑
LICENSE
NUMBER -1 Z I5 ASPHALT SHINGLES 11
LICENSED CONTRACTORS DECLARATION
I hereby chum That I am licensed under provisims of Chapter 8(commending with Secllon OOD SHAKES
71)1of Division 3 of the Business,and Professions Code,and my license Is In full force and
ate"' 3 OOD SHINGLES El
Ucenss Claes / 1 LIc.Numbe.rX2"1599
Date �� "Renlreclort 'P.Udylrj(ir OTH ECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby alllrm that I.am exempt from the Contractor's License Lew for the following reason.
(Sec.7031.9,Business and Professions Code: Any city or county which requires a permit to
poll alter,Improve,demolish,or repalr any structure,prior to Its Issuance,alio requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the piovailons
of the Contractors License law(Chapter 8(commenclnp with Section 7000)of Division 3 of Iib
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Business arW Protsssione Code)or that he is exempt therefrom and the bests for the alleged ASPHALT SHINGLES
exemption.Arty violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e crAl penalty of not more than five hundred dollars($501
❑I,as ownerof the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the worx,and the structure Is not Intended or offered for sale(Sec.701 Business ertd Proles-
eons Cade:The Contmdcs L"n re Law does not apply to an owner of property who Wilds or WOOD SHINGLES
U ❑
Improves thereon,end who close suwork himhill own f or through own employees,provided that
such Improvements are not Intended or offered for vele.If,however,the foul ci or Improvement
is sold will we year of completion,the owner-Wilder will have the burden N proving that he did OTHER(SPECIFY) Elnot buil Impious for Impifor purpose of sale.).
01,as owner of the property,am exclusive licensed conlmciwsto cronsiruct
III project(Sec.7044,Business and Profession a tractor's License law does not PROVIDE I.C.B.O.REPORT NO.
appy to an owner of property who Wilds or imp th ogand who contracts for such projects
with a contractor(s)licensed pursuant to the Contractors Ucense Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date COMPENSATION OECLAAA
WORKERD AP TION VALUATION PERMIT FEE
'S TION
I hereby affirm under penalty of peQury we of the lallowlng dedatatbn:
❑1 have and will maintain a Denlficate of Convent to sell-Insure for Worker's CompenseI �A Building
nce
as,provided for by Section 3700 of the Labor Code,for the performaof the work for whlch r''II 1�yQr�((��
perb�mlHT'Ile�u�will maintain Workers Oompensadon Inwurence,as required by Secibn 3] 1Jx7e7 Seism
iD
tM Lalwr Code,for ft performance of the wok for which Ws permit Is Issued.My W ` y
Compennfeet1w lin huurarca carrier and Po9cy number are: ZA-t l O `— Total
Confer 51^'r, FuKf . Policy Noy 11- IObLIU- TAUT ORIZATION DATE
CERTIRCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p
(This section Treed not W completed 11 the permit Is for one hundred dollars(5100)or I I OF`��
I certify that In the performance of the work for which this penult Ie blued,I shell not employ
any person In any manner eo as,to became subject M the workers'Camperaatbn Laws of Cali. All roofs shall be inspected prior to any roofing material being
fornix. installed. If a roof is installed without first obtaining an
Date Appllc,n C inspection,I agree to remove all new materials for inspection.
NOTICE TO Subject tothe orrkers'Cumpene ionProd na 11WrCodemro Exemption,you «Uwry Applicant understands and will comply with all non point
Mm ouch provisions or this permit shell be deemed eked. source regulations.
I certify that I have read this epplixm loo arM state that the above information le'corrian l agree
to comply with all city and county ordinances and state laws relating to Wltlingconetrucdan,and All roof coverings to be class"C"or better.
hereby aulhdrize moressntafivas of this city to enter upon the ebove-mentioned props
spa Wereyes.
(We)
agree
a to save,Irgcit
emnity and keep harmless e Clty of Cupertino a t 8edlitiee,
Iudgmonts,costs and expenses which may In any way accam against saki City In uence SIG E OF APPLICANT DATE
• of the granting of this 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY