R 6142•
CI
OFFICE COPY
PERMIT R_ 6142 .
NUMBER
APPLICATION FOR CITY OF CUPERTINO
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-5228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
16`3?, ?lis C16,
rJ 0
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
- HAZARDOUS FIRE AREA
YES ❑ If yes — I understand that a Class A
NAME V SAI ,VI
roof as iernbly is required.
NO ❑ Initial I.C.B.O. #
EXISTING ROOF COVERING
ADORES$-IOI82 1 lAl iL.T1 1ff���I•
/
PHONE 89 V
NUMBER OF EXISTINGCOVERINGS I
TO BE REMOVED TO BE RETAINED
CONTRACTOR'S ^
AME r.C•.,hJ
NADDRESS
�7I/�J'� �•,��
�'Ic--av�Jcse as�►�
TYPE OF ROOF COVERING
CITY&ZP_2—(04 / 1�T�1!
EXISTING
$ 5
PHONE
BUILT-UP ROOFLICENSE ❑ '
4
513oo
NUMBER I
ASPHALT'SHINGLES ❑
' LICENSED CONTRACTORS DECIARATION
- I hereby affirm that I am licensed under provisions of Chapter B (commencing with Section
WOOD SHAKES
7000) of Division 3 of the Business and Professions Code, and my license Is In full force and
-
effect.
License Cle ° Lid. Number
WOOD SHINGLES ❑
OTHER (SPECIFY) ❑
��.,,,r�
,4��=5,=I
Date I� ° Contrectdr'H11-cZfLs�L 1-/S riKl 4YY
• OWNER -BUILDER DECLARATION
I
PROPOSED
hereby affirm that I em exempt from the Contractor's License Law for the following reason.
(Sec. 7031.5, Business and Profession° 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'° License Lew(Chapter g (commencing with Section 7000) of Division 3 of the
Business and Profeesldne Code) or that he is exempt therefrom and the basis for the alleged
ASPHALT SHINGLES ❑
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars (5500 '
❑I,asownerolthepropewag a heir sole compensation, will do
WOOD SHAKES El.
the work, antl the air not in of or offe for ea c. 7044, Business and Profea-
alone Code: The on is Lice .w does n t pply t nor of property who builds or
Improves thereon, an does Imsel or throu own employees, provided that
WOOD SHINGLES ❑
Is such Improvements ntl.flin or offer kr agile. u, h e thebuildlng enof pros Improvement
ane year plellon,t o ne/r dBf)�h a burden of proving that he did
toltlid
notor
not build or Improve to car os ). D,V
OTHER (SPECIFY) p!mexi�ih:
U
❑ I, as owner of the partyxclus1vycontracting wl I Bad contractors to construct
the project (Sec. 7044, elness and Prolesslona Code: The License
PROVIDE I.C.B.O. REPORT NO.
ont Mor's Law does not
apply to an owner of pro ty who builds or improve° thereon, and o contracts for such projects
with a contractor(s) lice Bed pursuant to the Contractor's Llcana W.
El am exempt undo ,B & P. C. for the reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE VALUATION
PERMIT FEE
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,
�-77
as provide for by Section 3700 o1 the Labor Code, for the performance of the work for which this
permu eased.
I ZI1'�
BUIId In g
0
have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
Seismic Z 3
the Labor Code, for the performance of the work for which this permit Is Issued. My Workers
Compene ren Insurance carrier and Policy numbgr are:
Tota -212,30
L IO���`�V
PERMIT AUTHORIZATION
DATE
Cerrlero I)� Policy No.
CERTIFICATE OF EXEMPTIONFROM WORKERS'
COMPENSATION INSURANCE N.C.0
(TMs section need not be completed If the permit Is for one hundred dollars ($100) or lees.)
`
I certify that In the performance of the work for which this permit Is Issued, I shall not employ
-
All roofs shall be inspected prior to any roofing material being
any person In any manner so as to become subject to the Workers' Compensation Lowe of Cali-
fornia,
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
Applicant understands and will core
pP ply with all non point
NOTICE TO APPLICANT: If, after making this Certificate of Exemptlon, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
with such previsions or this permit shall be doomed revoked.
source regulations.
I'certify that I have read this application and stele that the above Information is correct. I agree
to comply with all city and county ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
All roof coverings to be classor bettfyj/
spection purposes.
(We) agree to save, Indemnify and keep harmless the City of Cupertino against Ilebllitles,
judgments, costa and expenses which may In any way accrue against said Clty In consequence
IG ATURE 1
of the granting of this permit.
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