R-6499 PERMIT
APPLICATION FOR CITY of CUPERTINO NUMBERR_ 6 49 9
INSPECTION DIVISION PERMIT EXPIRATI N
REROOFPERMIT (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 9,J Y1P 1,TV,
•4J_Via Lr-dP, CA'
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
_` 1` YES ❑ If yes-I understand that a Class A
NAME �l A U-�\ _. A>�U 2.V' O� ,.✓roof assembly Is required.'
NO �7 Initil I.C.B.O.7
ADDRESS 2-UGZ G �r''tt-� �f X950 '{ EXISTING'ROOFCOVERING
PHONE r (/ L -� NUMBER OF EXISTING COVERINGS
CONTRACTOR'S ((JJ p P,_ 1
NAME— IL C s&.< �o\�,A �r ,,. TO BE REMOVED TO BE RETAINED
ADDRESS /' TYPE OF ROOF COVERING
CITY&ZIP JL-P b ��SS(�T'c .5� W.
EXISTING
PHONE�xIy<6 l7 U� SrY BUILT-URROOF ❑
LICENSE
NUMBER �8 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby eBlnn that I am Ilcanew under provisions of Chapter 8(commencing with Section - WOOD SHAKES
7000)of DMskn 3 of the Business and Profeeelans Code,and my license a In fun force and
final WOOD SHINGLES
License Cleve J Lic.Number - ---'— ❑
Date �- ? ���� Cunha or ���� `C�-� �? OTHER(SPECIFY
OWNER-BUILDER DECLARATION •, D
I hereby affirm that I ern exemptPROPOSED from the Contractor's License Law for the following reason. I.
(SAPR ❑�
Sec.7031.5,Business and Professions Code: Any city or county,which requires a permit to QQ
construct,after,Immove,carnal or repair any structure,prior to Its lseuence,also requires the BUILT-UP ROOF
applicant for such permit to Me a signed statement that he is licensed pursuant to the provisions 11
of the Contractors License Law(Chapter 0(commencing with Section 7W0)of Dlvelcn 3 of the 1
Business and Professions Code or that he Is exempt therefrom and the all for the alleged ASPHALT SHINGLES
exemption.Airy Aphelion of Section 7031.5 by any applicant for a pertNt subjects the applicant to i r V
a C�Q ally d not more then Owl hundred!dollars dollars(55
Bl.es or of the property,or my employees with wages as their sola compensation,will do WOOD SHAKES
the work,and the structure Is not Intended or offered for sale(Sac.7044,Business and Pmfes.
alone Code:The Contractor's License Lew does not apply to an owner of property who pull or WOOD SHINGLES
w
Improves thereon,and who does suchhimselfwork himself or through his awl employees,provldetl that ❑
such Impromem9 are not Intended or offered for sale.It,however,the building or Improvement
is sok within one year of completion,the owner-builder will have the burden of prodng Chet he dd OTHER(SPECIFY) ❑
cwt bull or Improve for purpose of sale.). .
Pp es,owner of the property,am exdueNey wntractlrp with licensed contractors,to construct
the prWect(Sea Toa,Business and Proomens Code:The Contractors License Lew does rent PROVIDE I.C.B.O.REPORT NO.
appy to an owner of pmpmy who builds or Improvee thereon,entl who contracts for such projects
with a wntrectorts)licensed pursuant to the Contractors License Lew. PROVIDE MFGR. INSTALLATION SPECS.
C]I am exempt under Sec. ,B 8 P.C.for this reason
Owner Date U^T-F'4 L
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of iia following declaration: ��
❑1 have anti will maintain a Certificate of Consent to sell-insure far ati
r Workers Compensation, Building
as provided for by Section 37W of the Labor Code,for the performance of the work for which the permit
g
permit Is Issued. 1 D f O Q Seismic r/0
S44,t ve alk will maintain Workers Compansadon Insurance,as required by Section 3700 of y e r /
_the Labor Code,for the pedormence of the work for which tib permit Ie Issued.My Workers
Corrpeneetion Insurance caner and Polley number are: Total
•• 3LnS- PollcyNo. vyl -G(Cr PERMIT AUTHORIZATION DATE
CERTIFICATE OEMPTION FROM WORKERS' -
COMPENSATION INSURANCE N.C.0
(This section need not be completed it iia permit is for ane hundred dollars(4100)or less.) y 2-
I candy that In the performance of the work for which this permit Is esued,I shall not employ
any person In any manner se,as to became subject to the workers'Compemul Laws of Call- All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an.
Date Aicalcant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certmcate of Exemption,youshould became Applicant understands and will comply with all non point
subject to the Workers'Compansetion pro%ralons of the Labor Code,you must forthwith comply PP P Y
with such provlslons or this permit she nbe deemed rooked. source regulations.
I cannily that I have read this application ark state that the above information Is correct.I agree
to comply with all city and county ordinances anti state laws relating to bulking construction,and All roof coverings,to be class or better.
hereby auihodxe repremmatloa of this dry to enter upon the above-mentioned property for on. r
spectlon purpeaes.
(We)agree to wive,indemnity and keep harmless the City of Cupertino against llabllltles,
judgmants,costs and expenses which may In any way scans against said City In consequence SIGNATURE OF APPLICANT DATE
of the granting of this permit.
Sit 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 _�