R-6465 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 6 4 6 5
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)7/7-3228 PERMIT EXPIRES IF WORK IS NOT STARTED '
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1 B DAYS FROM LAST CALLED INSPECTION,
1 BUILDING ADDRESS
/✓A C 1 - RESIDENTIAL-4Z_COMMERCIAL OTHER
OWNERS / , HAZARDOUS FIRE AREA
NAME i I A/ 1, /-Y-'U�i / L Ec - �S ❑ �s I assembly
i reqand I[Inaire a Class A
assenlby is required
NO ❑ Iniliel .LC.B.O.111
ADDREss_Z�jry �� V0 N C'-7— EXISTING ROOF COVERING
PHONE 7 Z Z LO NUMBER OF EXISTING COVERINGS
CONTRACTOR'S /J
NAME �` R BO(�I`YU U TO BE REMOVED TO BE RETAINED
ADDRESS / TYPE OF ROOF COVERING
ClTvazIP EXISTING (-�-
PHONE - �7.rS- �'�6 BUILT-UP fa66F ❑
NUMBER Z - ASPHALT i HINGLES1 5 1993❑D
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am Ilcansod under provisions of Chapter B(commencing with Section WOOD Sl KES
7000)of Orval 3 of the Business and Protessons Code,wrtl my license Is In full lorca and
effec Q`v
ING
-
License Ll
enee Clec.Number C WOOD SH � C
Dab fComreaor G f G ' lN(✓- OTHER(SPECIFY) Zr 4 /
OWNER-BUILDER DECLARATION PROPOSED
I hereby al that I em exempt from the Contractors Ucenee Law for the foiWwing reason.
(Sec.7031 5.Sualness aro Professions Code: Any aty or county which ral a Permh to
construct,eBaq improve,deirtllsh,or repair any stmcture,prior to he Issuance,also requires the BUILT-UP ROOF
applicant for such permit to file a signed statement that he Is licensed pursuant to the proWnlons -
. .of the Contractors I-cause Law(Chapter a(commencing with Section 7000)of Division 3 of the
Bualnss that eand Professions Code)of t he Is exempt therefrom and the basis taw the alleged ASPHALT SHINGLES ❑
exemption.Any vblatlon of Section 7031.5 by arty applicant for a permit subjects the applicant to
a dull Penalty of not more than fW hundred dollars(55W).):
L]1,as Owner of the Property,w my employees with wages at Melr sole compensation,will do WOOD SHAKES ❑
Me work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Pmles. -
alone Code: The Contrait ctors License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,andft does such work himself or through his own amp orf provided that
such Improvements are not Intendad or offered for sale.If,however,the bulking or Improvement /moi
is a OW wmIn one year of completion,the owner-bullder will hes,the burden of proving that he plot OTHER (SPEOIFY] -/ /C.
not bulk or Improve fw purpose of vele.).
I,ae owner of the property,am exduslvely,contracting with Ilcanead corareclors to construct
the project(Sec.7044,Business and Professions Code:The Commcicre Ucenee law rices not PROVIDE I.C.B.O. REPORT NO. 4 Midi /n
apply to an owner of property who bulks or Improves thereon,and who contracts for such project
with a contractor(s)licensed pursuant to Me contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B 8 P.C.for this reason
owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby al under penalty of perjury one of the IoibMrg declaration:
• ❑I have and will maintain a canHbata Of Consent to sell-Insure for Workers Comparmatron, Building
as provided for by Setlbn 3700 of the Labor Code.for the performance of the work b which Me I
thepernitLa e Issued.
pensSeismic
❑1 he"and will maintain Workers Comation Insurance,we required by Section 3700 of
the Lobar Coda,for the performance of the 1w a la
which ihle permit sued.My Workers 'O
Compenaetlon Irocer
urance rfer and Policy number we: -7 S^,C/Q Total
Cartbr�T
? g
Policy No.?/3-F§--06z/L' PERMIT AUTHORIZATION DATE
CERTIRCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
The
io Section need not be completed II the pertnit le for one hundred tlollere(51100W))o or leve.)
I certify that In the performance of the work for which this permit Is Issued I shall not emq 0y -
any percwr In any manner so as to become Subject to the Workers'Compensation Lowe of Call- All roofs shall be i9specTed prior to any roofing material being
fert't 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,after making this Certificate of Exemptlon,you should become Applicant understands and will I with all non dint
subject to the Workers'Compenaethn wovlslons of the Labor Cade,you must brthwith compo PP comply Y P
with such provlelonv or Me permit sholgbs deemeo reSource regulations.
I certlfy,that I have read the application voked.n entl state that the above Information Is correct.I agree
to comply with all city and county ordinances and state taws relating to bullding construction,and All roof coverings to be class joOr Better.
hereby authorize reprowntharas of this city to enter upon the abmnamentioned property for In.
apection purposes.
(We)agree to esus,Inromnlfy aro keep hermleas Me City of Cuiol against Ilabllitles,
• coat and eenses which lnet may In any way accrue egeseltl CRY
of the gran encs, xp
In wnsequence
al the n of Mb permlf. SIGNATURE OFAPPLICANT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY