R-6496 PERMIT R_ 6 4
APPLICATION FOR CITY OF CUPERTINO ,
NUMBER
INSPECTION DIVISION PE MIr XPIRATION
REROOF PERMIT (ao8) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS
(C) 00i
RESIDENTIALCOMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME Ill D q U ` C A roof assembly Is required.
U Q.--) ti a NO Initial I.C.B.O.Y
ADDRESS `� rt.S � '"- �s�4 EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONITRAC 0F'S
NAME -��, x Y TO BE REMOVED TO BE RETAINED
I� w_� �.n
CIDS
` TYPE OF ROOF COVERING
CITY&ZIP � u L•� Se'1-1 St• Ate+
Shit{� U.. " l r cl S vST�{ EXISTING
PHONE �L(a ll G 2 Q &2&q BUILT-UP ROOF ❑ '
LICENSE
NUMBER I ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECIJJiAOON
I hereby entrm Net I am Ibened under proWebn of Chapter a(cwrvrwrrdng with Section WOOD SHAKES
7000)of Division 3 of Ne Business and Professions Code,and my license is In full brae and
ened. G 37Sg l . WOOD SHIN
License Class Uc.Number - i il) II l I i
Date y-2` �� `l convector ',�es•e3 - Us '• OTHER(�P_�CIFY) 26 1999❑)II
OWNER-BUILDER DECLARATION PROPOSED�Ii� R ,VI
I hereby affirm that I em exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Business entl Professions Code: Any city or county which requires a permit to
ewxstruct,after,Improve,demolish,or repair any stmcture,prior to Its Issuance,am require¢the BUILT-UP ROOF
applicant for such permit to ills a signed statement that he f scented pumam000)o to the prwof the dy
of Ne Contractors emit o Lew(Chapter B(eammenqrg ws U Section 7000)of o the
3 of the
Business and Professions Cotle or Net he Ie exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant far a Permit subjects the app0cant to
t e civil penalty of not more than five hundred dollars
0,as owner of the property,or my employees with wages as Melr We compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sac.7044,Buslnew and Pirl
son
pswCae tlwrimCerWwho doees such wworkdfineen«tpply hrough his own`empllvyees,Povided that
property wM builds or WOOD SHINGLES Q
such Improvements we not intended or offered for sale.ll,hovraver,the buldkg w Improvement
is sod within one year of completion,Ne owner-builder will hese the burden of proving that he db OTHER (SPECIFY) ❑
not bulk)or Improve for purpose of vele.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
wIN a contmctons)licensed pursuant to the Contractors license law. PROVIDE MFGR.INSTALLATION SPECS.
C]I em exempt unc er Sec. ,B d P.C.for Ws reason
Owner Date
WORKER'S COMPENSATION OECLAAATON APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the Wowing declaration:
❑1 have and will maintain a Certnlcete of Consent to self-Insure fw Workare Compensation, BUlldlnV
as provided for by Section 3700 of the Leber Code,for the performance of the work for which this �7 w
perms Is Issued - - �j O �y Seismic ��
❑1 have and will maintain Warker's Compensation Inuraroe,as required by Section 3700 of
the labor Code,for the performance of Ne work for which this permit Is is dMy Workers ,' •'�/^�
.Compensadon Insurance carrier and Policy number are: Total
Carrier PdkyNo. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C{]
(This section need not be completed If the permit is for oro hundred dollars($1 DO)or less.)
I certify that In the perforrnnco of the work for which this permit Is Issued,I shell rot employ
any person In any manner as as to become subject to the workers'Compenatbn Laws of Cali- - All roofs shall beinspected prior to any roofing material being
for"iainstalled. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPUCANT: If,after making this Certificate of Exemption,you should!become Applicant understands and will I with ail non point
subject to Ne Workers'Campenanion provision of the Labor Code,you must foMwMh complyPP comply Y P
with such provisions or this permit shell be deemed revoked. source regulations.' -
I certify that I have read this application and suMe that Ne above Into mason Is conect.I agree
to compty with all Gly and county ordNences and state Ia"relating to bullding consthuction,and All roof coverings to be class or better.
hereby authorize representatives of this city to enter upon the above-mentbnd property for In.
spectbn purposes.
(We)agree to save, Indemnity arta keep harmless Ne Cry of Cupertino against liabgdics.
rudgments,coins and expenses which may In any way accrue against said City In consequeroe SIGNATURE OF APPLICANT DATE
d the renin of Iola perms.
r, PRE-INSPECTION: LYWOOD: N-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