R 6185E
OFFICE
S PERMIT R- 6185
APPLICATION FOR CITY OF CUPERTINO BE
INSPECTION DIVISION PERMIT EXPIRATION
REROOF.PERMIT (408) 777-3228 PERMIT EXPIRESIF WORK IS NOT STARTED
WITHIN
_ WITHIN DAMS OF PERMIT ISSUANCE OR
FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
100'11 � lOo"r5 R�!•IPMSfiA h�
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
YES ❑ If yes — I understand that a Class A
NAME P LYE GQDEI�
roof assembly is required. '
NO ❑ Initial I.C.B.O. #
•
ADDRESS _3 Gc) Fi2XBO aQU&G +F
EXISTING ROOF COVERING
PHONE
NUMBER OF EXISTING COVERINGS t
TO BE REMOVED I WeS TO BE RETAINED
CONTRACTOR'S
NAME S4$17 MAl Rn'r -*&
ADDRESS
TYPE OF ROOF COVERING
CITY&ZIP yww
EXISTING
PHONECL61 -7649.
BUILT -UP ROOF ❑ yyy
LICENSE
NUMBER kt4cll, I
ASPHALT SHINGLES 7�
'
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
WOOD SHAKES
7000) of Division 3 of the Business and Professions Code, and my license Is In full lone and
effect.
WOOD SHINGLES ❑
License Class CZZI!� Lic. Number Z Ct to f
/
Data IL�'t -+'2� Contractor S��a� ��-j
OTHER SPECIFY
( ) ❑ .04Y
Y PROPOSED
OWNER- BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
/
(Sac. 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
applicant for such permit to file a signed statement that he is licensed pursuant to the previsions
ROOF
BUILT-UP ❑ IM �Y.
of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business Professions Code) met he Is
and or exampl therefrom and the basis for the alleged
exemption. Any violation Section 7031.5 by
ASPHALT SHINGLES GO�•(1r �
of any applicant for a permit subjects the applicant to
a civil penally of not more than live hundred dollars ($500).):
❑ I, as owner of the property, or my employees with wages as their Baia compensation, will do
WOOD SHAKES ❑
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Profas.
-
sions Code: The Contractor's License Law dues not apply to an owner of properly who builds or
improves
WOOD SHINGLES ❑
thereon, and who does such work himself or through his own employees, provided that
such improvements are not Intended or offered for sale. 11, however, the building or Improvement
Is sold within one year of completion, the owner - builder will have the burden of proving that he did
not build or Improve for purpose of Baia.).
OTHER (SPECIFY) ❑
❑ I, as owner of the property, am exclusively contracting with licensed contrectore to construct
the project (Sec. 7044, Business Professions Code: The Contractors
PROVIDE I.C.B.O. REPORT NO. 151
and License Law does not
apply to an owner of property who builds or Improves thereon, and who contracts for such projects
with a contractors) licensed pursuant to the Contractor's License Law.
PRONTO S.
❑ 1 am exempt under Sec. ,B 8 P. C. for this reason
Owns( Date
WORKER'S COMPENSATION DECLARATION
APPLICATION
TE
UAT
N 11
PERMIT FEE
hereby affirm under penalty of perjury one of the following declaration:
❑ have and will maintain a of Consent to salt - insure for Worker's Compensation,
for Worker's
���xa
�`{J
Ullding
of thel Lab
for by Section 3700 of the Labor Code, for the performance althe work for which this
/� —Z,—�
� r
pemitis Is
permit thane ed.
'Edl have and will Workers Compensation Insurance, as required by Section of
ISmic t 70
the p or Code, for the p arrer and of the ware for which ihle permit Is Issued. My Worker's
the performance rmanc h this orke
Compensation Insurance carrier and Policy number era:
r� V
B
/
tal �%' 7c)
Carrier LIECA J Policy No. t6_—ZC6 7-6tZ6
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
�Vi aiK. r'
/Q —2--ci (/
COMPENSATION INSURANCE N.C.❑
(This 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 to Issued, I shall not employ
Ell.
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 Laws of
fofnia.
installed. If a roof is installed without first obtaining an
Dale 10 L- �1_ Applicant Sl
inspection, I agree to remove all new materials for inspection.
Applicant understands and will comply with all non point
NOTICE e APPLICANT:
subject orrk �as'Compen after making PrOV1s� this o hell borrCoode you must foenwiih comply
with such provisions or this permit shalgbe deemed revoked.
source regulations.
I certify that I have read this application and state that the above Information Is correct. I agree
to comply with all city and county ordinances and state laws relating to building construction, and
All roof coverings to be class "C "or better.
hereby authorize representatives of this city to antar upon the above - mentioned property for In.
spection purposes.
(We) agree to save. Indemnity and keep harmless the City of Cupertino against liabilities
�r� ^,mow �- j� �,r� a
judgments, costa and expenses which may In any way accrue against uald City In consequence
of.the granting or this permit.
SIG ANT 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