R-6080 PERMIT R_ 6080
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT. (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
- WITHIN IN DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
O 1 e S RESIDEN-1AL—k—COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
l4X ,M P,� nee r� v YES ❑ Myes
—I underriand that a CIMA
NAME roof assembly is acquired.
NO ❑ initial I.C.B.O.M
ADDRESS 1 ('I hQ EXISTING ROOF COVERING
PHONE — 5�D O, - NUMBER OF EXISTING COVERINGS
CONTRACTOR'S n
NAME T/4'-V�c,r P,!,- �1 M Co r TO BE REMOVED TO BE RETAINED
/
CADDRESS ITY a ZIP-10,53 -S ,. 7 C _s-7 .
S rU r TYPE OF ROOF COVERING
ExisnNG
PHON( K0457 ,cSOBUILT-UP ROOF ❑
LICENSE SPHALT SHINGLES 71NUMBER
LICENSED CONTRACTORS DECLARATION
- I hereby enlnn that I em Ilceruw and
Professions
of e,and a(commenting with Section WOOD SHAKES
7(00)of DMebn 3 of the Buslneae entl Proleeslone Cade,entl rtry license le In lull force entl
affect.
OOD SHINGLES ❑
LIaenee Cis" C-32 LIa.Numb., 'YS Zo / 6
Date g Comractor 7Ay4. ,- l/ PECIFY) ❑
OWNER—BUIL—DER DECLARATION PROPOS
I hereby elflrm that I em exempt from the Con,radora License Law for the following reason. -
(Sec.7031.5,Business end Professions Code: Any city or county which requires a permit to ftill
construct,after,Improw,demolish,or repair any stmtlure,prior to its Issuance,also requires th /eBUILT-UP ROOF ❑
applicant for such permit to file a signed statement Mat he Is licensed pursuant to the provlelons
of the Contredces LIcenee Lew(Chapter 0(commerwing wIM Section 7000)of Division 3 of the -
Business and Profeeabne Cade)or that he Is exempt, arefrom and the basis for the alleged �I$PHALT SHINGLES
exemption.Any vloledon of Section 7031.5 by any applicant fm a permit subjects the applicant to /
a civil penalty of not more than I"hundred dollars(5500)J:
C]1.as owner of the property,or my employees with wages as their sole componselloo,will do SHAKES ❑
the work,and the structure Is not Intended or offered for Sale(Sec.70x4,Business and Proles-
alone Code:Tha Central license law does not apply to an owner of property who builds or WOOD SHINGLES ElImprowe Merecn,and who deals such work himself or through his awn emplowes,provided that
such Improvements are not Intended or offered for sale.If,howel the building or Improvement
is sold within one year of completion,the owner-Wilder will have the burden of proving that he did OTHER(SPECIFY) ❑
rrot Wild or Improve for purpose of sale.).
❑I,mwnerof Mepmperty,emexduslvetycwtraen�+g withllceneedcomractonetocc sft t
the proles(Sec.7044,Business and Professions Cade:The Contractors License Lew does not PROVIDE I,C.B.O.REPORT NO.
apply to an wear of property who builds,or Improws thereon,and who contracts fa such projects
with a cmtractor(a)licensed pursuant to Me Contractors License Lew.
❑1 em exempt under Sec. ,B 8 P.C.for this reason PROVIDE Nl INSTALLATION SPECS.
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECI-ARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have end will malmaln a Ceddicate of Consent to self-insure for Workers Compenea,lon, Building •UV
as provided for toy Section 3700 of Me Leber Code,for the pedormartce of the work for which this ��
permit Is Issued. /2/ Seismic ' To
DI(heva and will mountain Worker's Campensanon Irroumrwre,as required by Seci#171081� Q�f�,h icor Cab,fa Me Performance of Me work for which Oue permit Is Issued.MCampensstion Insurance carrier nd Policy nurroer ere: Total 71 Y•9t3Carrier �TF �w/L Policy Na -P RMIT HO TION DATE
CERTIFICATE OF EXEMPTION FRAM WORKERS'COMPENSATON INSURANCE 100(This sedlon neetl not ba mrtWleted II the permh b for are hundred dollars(5100
I certity,that In Me performance of the work for which this Permit is blued,I shell not employ
any person in arty manner so as to become subtecl to the Workers'Compensation laws of Call- { oofS shall be I ted prior to any roofing material being
fornb. in d. If a r Installed without first obtaining an
Data
Applicant inspec agree remove all new materials for inspection.
NOTICE TO APPLICANT: If after making this Cadmca,e of Exanpibn,you should become Applicant Un nds and will Com with all non OIDt
subject to the Workers'Compensatlan provisions of,he labor Coca,you must forthwith comply pp comply p
win such provislo or this permit shell be deemed revoked. Source regulations.
I call that 1 haw read this appikatlon ad state that the ebare Information Is correct I agree
to comply wdh all dry and county ordinirl and state leve relating to Wilding conevuctbn,antl All r�fc v�n s obeclass"C"or better.
hereby eutlrize nepnesentiarms of the city to enter upon the above-merdomW property for In.
lsfxctlePurposes.
(We))agree to save,Mtlemhiw end heap harmless cI It a of Ct said eaalne,Ilebllltlee, (O.
jutlpmems costa and expenses which may In any way accrue egelne,Geld Clty In wneequenca
:. ofihegrLr)tbgamile Permit. - SIGNATURE OF APPLICANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE - INSP. DATE INSP. DATE
TEAR OFF I PECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY