R-6342 PERMIT
APPLICATION FOR CITY of CUPERTINO NUMBER R- 6342
.
INSPECTION DIVISION - PERMIT EXPIRATION
REROOF PERMIT (408)'777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 190 DAYS OF PERMIT ISSUANCE OR
190 DAYS FROM LAST CALLED INSPECTION.
' BUILDING ADDRESS (\�' _
10030 - CL Aj 1 G /3 L. V 6 RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
GL Som/ YES ❑ Hyes-IunderstandthataCLmA
NAME cool assembly is required.
_ NO ❑ Initial LC.B.O.P
ADDRESS GEXISTING ROOF COVERING
PHONE �•� _ O . NUMBER OF EXISTING COVERINGS /
CONTRAC OR'S Y
NAME �T 7 .r �C'�'�• TO BE REMOVED " TO BE RETAINED
ADDRESS 6, Sa� Jx6 99-1 9- TYPE OF ROOF COVERING
' CITU 8 ZIP 'f� 0 6ll EXISTING
PHONE. '�""� �f T / - BUILT-UP ROOF ❑
NUMBER �r•� ASPHALT SHINGLES ❑ .
LICENSED CONTRACTORS DECLARATION \ ,
I hereby affirm that I am Ikensad under provistone i f Chapter B(commencing with Section WOOD SHAKES g
7000)of DMsion 3 of the Business and Professions Coca,and my license le In full force and
effect. C�- 7 ( /S3 WOOD SHINGLES ❑
Ucense Cl Lk.Number
Date - Coniraclor Cl L/l d L 1 Ci OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I notably affirm that 1 em ept xemfrom the Conlradcls License Lew for the IolloniO g reason.
(Sec.7031.5,Business and Profeeabns Cade: Any city or county which requires a permit to
conerinW,after,Improve,danwNah,or repair any structure,prior to its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such Permit to We a slgnatl statement that he Ie licensed pursuant to the Prwisions
of the Contractors License Law(Chapter 9(comme ong with Section 7000)of Division 3 of the
• .Bummers and Prdesabne Cade)or that he Is exempt Cherefrom and the basis fa the alleged ASPHALT SHINGLES El
a civil)peneltmof net violation of Mein live hundred en 7031.5 dolllaarsp(S500).lcarrat�or a permfl sublacLs the applicant to
WOOD SHAKES ��R
❑Les owner of Mature is y,on to ced or oee with wages as o 7 ode compensation,will do
the work,end th structure Is rot inteMed or offered for sale(Sec.7(W,Business and Proles-
None Cade:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLESr
Improves thereon,ani who does such work himself or through his own employees,provided that ❑
Such Improvements are not Interideo or offered for safe.ff,however,the building w Improvement
Is sold within one year of completion,the owner-bulkier will have the burden of proving that he tlk OTHER (SPECIFY) ❑
not buld or Improve for purpose of Sale.).
❑I,as owner of he property,em exclusively contracting with licensed contractors to construct
the protect(Sec.7044,Business and Professions Code:The Contractors Lcenee Lew does not PROVIDE I.C.B.O.REPORT NO.
applyto an ownor of property who builds or Improves thereon,and who contracts for such projects
with a confrador(s)licensed PareuBnt to the CantmCtore LJCenae law. PROVIDE MFGR.INSTALLATION SPECS.
F7 am exempt under Sec. ,B 6 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury ora of Me fdiowing dedaration: //
[:]I have and will maintain a Cenlflcate of Consent to self-insure br kers WorCompensation, Building b
as provided for by Section 37W of the Lmnor Cotle,for the pudormance of the work for which this
per�^�e Issued. OD Seismic /
Zo
lfI have and wool melnteln Workers f the work
"Ich this as required by Sachin Worker's
/ (] /
C bar tion I for the pedormance of the work fon which Mb permlf is leeued.My Workers /
Compensation Insurance cerderlyk Policy umber ere: TOta
Carrier 13" TC ;= f� Policy N0.6/06l PERMIT AUTHORIZATION - DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C{] (Y
(Thio section need not be completed II Me permit is for one hundred doNma($100)on lees.) T(/•
1 ownty Met In Me perknmance of Me work for which this permit Is bsued, shell not empty
ary person In any manner act as to become subject to Me worke%Companeetbn Law.of tail. All roofs shall be inspected prior to any roofing material being
fomk. installed. If a roof is intedal
fel ' g an
Date APpllcant inspection,I agreetoremorin tion.
NOTICE TO APPLICANT: If,after making MIs Certificate d Exemption,you should become A IICanI understandsll Olnt
subject to Me Workers'Compersation prwlNons of Me Labor Code,you mum forl comply. pP Pwoh such Pav ebne or MIs permit Nuri be deemed revoked. source regulations. - 9I certify that l have read MIs application and mate Mat the above Internal la correct I agree to campy with ell city and count'ordtrances and male laws relating to building constructioq and All too c eringsto bahhereby authorze nepreeentatives of his city to enter upon the ebwre-mentioned property M In- �—
spade)agreto 1W`ply) /P
(We)agree to al s Indemnity ark keep harmless;the City of Cupertino against IIequen e
Judgments,Cae19 entl expenses which may In any way accrue apelnm Bald Gy In consequence SIGNATURE OF APPLI
•
or the granting of this Parmlf.
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
OFFICE COPY