R-6411 PERMIT R-
APPLICATION
APPLICATION FOR CITY OF CUPERTINO NUMBER 6411
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-8228 PERMIT EXPIRES IF WORK IS NOT STARTED
. WITHIN DAYS OF PERMIT ISSUANCE OR
1I DAYS
SFFR OM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL—)—( COMMERCIAL OTHER
OWNER'S C HAZARDOUS FIRE AREA
NAME J �� d I�, VES )1}llf yes s I assembly
is required. Class A
rgol assembly is required. e.0
NO ❑ Initial LC.B.O.
ADDRESS ?- L. �* �—C�. ` . EXIS'nNG ROOF COVERING
PHONE — a7 - NUMBER OF EXISTING COVERINGS
CONTRACTOR'S v
J�LI n1 U171 R�►AO'" I.�N�-/ TO BE REMOVED TO BE RETAINED
NAME
ADDRESS ! O� a ,4� ,� � TYPE OF ROOF COVERING
CITY 8 ZIP 2: -
e" �
q EXISTING Vjrx7
PHONE - •"L� + �� /,j�i BUILT-UP ROOF ❑
LICENSE ❑
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby all ton met em Business
and
Pr fess ns of Chapter a(coma eis In with 9e and WOOD SHAKES
71X10)of DMebn 3 d nre Business entl Prolessbns Code,and rtry license f9 In fuA force entl
a"s ` W006 SHINGLES ❑
IClass� Llc.Number �� D
DateContractor OTFIf R(NPH 19)0 1999 El
OWNER-BUILDER DECLARATION PROPQSED
I hereby anm lrm mat I aexempt from the Contractors License Lew for me bNIw g reason.
(Sec.7031.5,Business and Profneslbne Code: Any city or county which re holres a permit to
corretruct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT l�P ROOF ❑
applicant Co for etch Perron to na a signed statement that g Is Ilca cu7WOpursuer,m the Pravof ma 1
of me Contractors License Law(Chapter B is ex a pt therefrom with Section 7000)of for the 3 til ed ❑
Staines end doia ton f Satla)or that he is exempt foand ma belle for applicant
alleged to ASPHALT SHINGLES
a cMl Pen.Anyvlotm of Semon 7031.5 by any eppUcent fora permit aubincle me applceni to
a cMl penalty d not more then IWe huMred dallers
01,as owner of the property,or rmy,smployeas with wages as their sae compeneanon,will do WOOD SHAKES ❑
the work,and the structure Is not intended or offered for We(Sec.7044,Business and Profes-
alone Code:The Contractors License Law does not apply to an owner of property who bulb,or ' WOOD SHINGLESdlr
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not intended or offered for sale.It,howaveq the building or improvement ZQ+l,7
Is sold within one year of completion,the owner-builder will haw the burden of proving that he did OTHER(SPECIFY)
not build or Improve for Purpose of sale.).
❑1,as owner of the property,em exclusively canbectlr�g with licensed cantmm ctoto construct
the project(Sec.7044,Business and Profeeslons Cade:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO. y�
appy to an owner of property who bulla or Imprmea thereon,entlw contracU for such projects
with a contmcfogs)Ilcansad pursuant to the Contreaors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 6 P.C.for this reason
Owner T
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION, PERMIT FEE
IO
I hereby affirm under penalty of perjury one of the following declaration:
❑1 haw and will maintain a Cendicere of Consent to WrInsure for Workers Compensation, Building 49
P o 7
is provided for by Section 37DD of the Labor Code,for the performanof the"A for which IN.
g /
providedce
perm1 31 owed. ^
��1((1��1''hew entl will maintain Worker's Compensatlon Insurance,as required by Section 3700 of l.� V Seismic
ih^bor Cade,for the performance of the work for which mle permit la Issued.My Workers
Compensation Insurance corder and Policy number are: Tota/
Carrier. V(gI1/114 Ptsll+atl PlNo. 2COCU3�3 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N
(This section need not be completed If the permit B on
for e hundred collars($100)00)or lase.) Y
I certify met In the performance of ma work for which this permit is Issued,I shell not amplay
any person In any manner so as to become subject to the workers'Compensation Laws of Call. All roofs shall be inspected prior to any roofing material being
fomla - 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,akar a wing this Cernficate of Exemption,you
ac. 'Applicant understands and will comply with all non point
subject to the Workers'Comparaatbn provisions of I e Labor Code, comply
with such Prods s or INs permit shalcbe deemed revoketl. source regulations.
I parity that I hew reed this application entl state that the above Information is correct I epee
to comply with all city and county ordinances and state laws relating to building conslructbq and All 1rEcverin0&ta e a or better.hereby authorize reprssentatwe of this dry to enter upon the above-mentioned property for In-
spection purposes.(We)epee to sew.Indemnty antl keep harmless the City of Cupertino against liabilities.
udpmenu,costsantlexpenses which may m day way accrue against rand Ciy In consequence
of the gestin of this permit. SI TUn APPLICANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. - DATE INSP. RATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE- INSP DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY