R 6011 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R 6011
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 150 DAYS OF PERMIT ISSUANCE OR
150 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
914 '
'' T2(4 13fnAlil AV' RESIDENTIAL COMMERCIAL OTHER
OWNER'S �y HAZARDOUS FIRE AREA
NAME IMS. S�,4*-1 VES ❑ troof assernbly s required Class A
NO ❑ Initial I.C.B.O.If
ADDRESS EXISTING ROOF COVERING
PHONE ?,SZ-f¢S-'$S NUMBER OF EXISTING COVERINGS z
CONTRACTOR'S.' - \1 n__
W I L.C.(/kIL�S l'-�"�'� TO BE REMOVED 2' TO BE RETAINED
NAME / E'^�'�' A
ADDRESS (a3 Y X44 D►Klf+s W� `u�bKE TYPE OF ROOF COVERING
CITY&ZIP EXISTING y
PHONE BUILT-UP ROOFLICENSE
❑ " / � A
NUMBER 47140199 ASPHALT SHINGLES , Zp
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter g(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business end Professions Code,end my license Is In lull force and
affect. �{ q �''• WOOD SHINGLES El
License Claes Lid.Number •7 y 79
Date 7/Z ft a Contractor � �-- OTHER(SPECIFY) ❑
OWNER-SUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractors License Lew for the following reason,
(See.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,improve,demolish,or repair any structure,prior to its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter B(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLESYR"
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penally of not more than five hundred dollars($500).):
❑l,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
setons Code;The Contractors License Lew does not apply to an owner of property who builds or WOOD BHIFI
Improves thereon,and who does such work himself or through his own employees,provided that OLMI) ❑
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHE E IF
not build or Improve for purpose of sale.). r
❑1,as Owner of the property,am exclusively contracting with licensed contractors to construct UL
y(�s JIj�
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE LC.B.O.ART RT N0.
apply to an owner of property who builds or improves thereon,and who contracts for such projects GIIY 4.`INS`YAtLATION SPECS.
with a conlractoris)licensed pursuant to the Contractors License Law. '
❑I am exempt under Sec. ,B 8 P.C.for this reason PROVIDE MIyGI1
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, Building 7•
as provided for by Section 3700 of the Labor Code,for the performance of the wok for which this //�
permit Is issued. - 7/Z'? / ( $ I Sob Seismic
❑ have and will themaintainrt Worker's Compensation the wokfor Insurance,as required by Section 3700 0l 1/ 1 T
.the Labor Code,for ins performance of the work r a which this permit is Issued,My Workers l �o
'
Compensation Insurance carrier and Polley number are: Total [.L1 '✓
Carrier Q VVL"d Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit is for one hundred dollars(5100)or less.) 9
I certify that In the performance of the work for which this permit Is Issued'I shell not employ V
any person in any manner so as to become subject to the Workers'Compensation Laws of Cell. All roofs shall be inspected prior to any roofing material being
forma. \ qn installed. If a roof is installed without first obtaining an
Date Z''t 9 C Applicant V"`I� inspection,I agree to remove all new materials for inspection.
NOTICE TO PPL(CANT! If,after making this Certificate of Exemption,you should become Applicant understands and will 'comply subject to the Workers'Compensation provisions of the Labor Code,you Comply I with all non point
u moat forthwith cora PP P y P
with such provisions hat Ihav ribispermitscation deemed that revoked, SOUfCe regulations.
certify thatIhave antl thisapplicationordinancantlsatethattheabove Information iscorrect. agree
to hereby authorize
repcity and county of this cos and ter upon
thela0n to ve-me tined Property f,and All roof coverings to be class"C"or better.
hereby epurpo a represantativea of this city to enter upon the above-mentioned property for Ira .�
apecllon purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against loabllities,
judgments,costa and expenses which may In any way accrue against said City In consequence
of the granting of this permit. SIGNATURE OF APPLICANT DATE
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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY