R-6078 PERMIT R— 607
8 -
APPLICATION FOR CITY OF CUPERTINo NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
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 /'1 r
0233 vt A•� &-o � Q Q Ile C\\ C � RESIDENTIAL//�\` COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
y�/� 1/•� f �-, YES ❑ If yes-I understand that a Close A
NAME ' " \ `J i l roof aeaernbly is required.
/ NO ❑ Initial LC.B.O.R
ADDRESS
IO k6 (04 - EXISTING ROOF COVERING
T `
PHONE Q 3✓ NUMBER OF EXISTING COVERINGS
CONTRACTOR S // �//1,,,� (�
NAME�K i l9\r A&-., TO BE REMOVED�_TO BE RETAINED
ADDRESSc' S cls/ TYPE OF ROOF COVERING
CITY aZIP—
�l7�J � S 7� -T` s, ' l EXISTING
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PHONE ( / �� 7J C� _ B
LICENSE
NUMBER S t� AS yi3k4 SHl LpE ❑
I hereby eftinn Net I am censedLICENSE0under pprrWsbne of CTORS Ch Chapter 810((commencing with ctcn D W on�{ Se*09 V D ❑
]000)of DMsion 3 of the Business,and Promealons Coda,and my license Is in lull o entl �V� �i,
affect. 7 /
C�3 sL 6/G W D SHINGLES ❑
Ucanw Cmas Lc.Number -7J H
Date- r1 - 2 Conirector �r '^-�� r O -
OWNER-BUILDER DECLARATION P ED '
I Hereby affirm that I am exempt from the Contractors Lcense Lew for the blbwlrg reason. /
(Sec.7031.5,Business eM Professions Code: Any cfty or county which requires a permit to
construct.alter,Improve,demolish,or repair any structure,prior to Its Issuance,sleo requires the
coper)f ILT UP ROOF Elapplicant for such permit to file a signed statement that he Is licensed pursuant to the proNelons' T
of Is Contracture License Law(Chapter B(commendrg wMh Section 7000)of DMson 3 of the
• Business and Profession Coda)or that he Is exempt Therefrom and the baste ict the alleged ASPHALT SHINGLES ❑
exemption.Any violation d Section 7031.5 by any pplicant for a permit subjects the applicant to
a civil penalty of not more Men five hundred dollonr(5500).):
[3 1,as owner of The property,or my employees wlh wages,as,Their sole compensation,will do WOOD SHAKES - ❑
Ne worn,and the structure Is not Intended or aHered ler sale(Sec.70",Business and Proles.
alone Code: The Contractors l-cones Law does not ppty to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who doo.such work himself or through his own employees,provided that ❑ \
such Improvements are not Intended ur offered for sale.If,however,Me bantling or Improvement
Is edit within one year of omplabon,the owner-bulkier will have the burden of prming That he did OTHER(SPECIFY)
not build or Improve for purpose of sale.). /—
I,as owner of the property,am exclushely conlrectlrp win licensed ccniredors to construct
Me project(Sec.7Ul4,Business and Prol¢salons Code:The Contractors Lloenee Law,dome not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improve,Hereon,and who contracts ler such projects
with a ontractorm)licensed pursuant to the Contracture License law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B S P.C.for this reason
owner Date
WORKERS COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
'
I hereby affirm under penally of perjury one of He following declaration: 12
1 have and will maintain a CmtlHkate of Consent to self-insure for Workers Compensation, Building v
as prmided ler by Section 3700 of Me Labor Code,for the performance of He work for which this
°eoIewed' g QOO Seismic /�6
�rtt hove and will ondthepe rf Worker's Compensation work
wrich rte,m rmit is I u Section 3]00 01 /
Jodi Lobar Cade,for the performance and of Me work for which Nb permit is Issuetl.My workers
Compensetlon Insurance center entl Policy number ere: Tote
Carrier � rn, A- S.?' PERMIT AUTHORIZATION DATE
PROM W
CERTIFICATE EN EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C[I '
(TNe section need not be completed l Me permit Is for one hundred dollars(5100)or less.) T'O
I pertly that In Me performance of Me work ler which Nle permlt Is Issued.I shell not employ
any person In any manner an,as to become subject to Me Works'Compensation Lara of Cell- All roofs shall be inspected prior to any roofing material being
mmW. 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 his Certficete of Exemption,you should become Applicant understands and will comply with all non Dint
sublect to tris Workers'Compeneetlon p.Wons of the Labor Code,you must forthwith comply pP P Y P
with such provisions or this permit shell be deemed revoked. source regulations. -
I tartly that I have read NW applbatlon and state that the shove Information Is correct I agree
to comply with ail dry and county ordinances and state laws reletlng to building conatructloo,entl All roof RE OF coverings to be class"C"or better. n`
hereby aeltlmo a repreeenTetives of Nle dry "ter ter upon Ne ebavn-rnentloned property roc In.specdon `/�4"^`' /V/`_�.
(We)agree to esus,Indemnify and keep harmless Me City of Cupertino against liabilities, p
Judgments,oats and expenses which may In any way accrue against eeltl Clry In oneequano
of me granting of Ne permft. SI NATUAPPLICANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE/0 f9 INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY