R 6090 PERMIT R_ 6 0 9 0
APPLICATION FOR CITY OF CUPERTINO NUMBER
R-
PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• -
BUILDING ADDRESS 180 DAYS FROM LAST CALLED INSPECTION.
Z/ �,[� (^
T J / RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME roof assembly is required.
/'ASI /�C-1 � � NO �❑ Initial I.C.B.O.N
• AooREss_ I�--1U m 4 f EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTO{P�'S � ' I
NAME +� TO BE REMOVED BE RETAINED
ADDRESS_ s ` U TYPE OF ROOF COVERING
CITY&ZIP
PHONE 0 BU�II��LT�--UUQP F ❑
NUMBER b CGLICENSE SE 7kSWfi7TCT GLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provislons of Chapter 8(commencing witfiction WOOD SHAK S yrs
7000)of Division 3 of the Business and Professions Code,and my license Is In full entl -
affect. 4&6 /( Z By INGLES ❑
License Cles Uc.Number �('
Date ��Contractor OTHER(SPECIFY) ❑
OWNER.BUILDER DE ARATION PROPOSED
1 hereby affirm that I em exempt from the Contractor's License Lew for the following reason.
(Sec.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 ❑ v
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor'.License Lew(Chepler g(commenting with Section 7000)of• Dlvlsion 3 of the Business entl Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLESI^
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a clvll penalty of not more than five hundred dollars($500).):
Ll 1, SHAKES
1,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
alone Coda:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
is sold within one year of completion,the ownef-bulldbr will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑Loa owner of the properly.am exclusively contracting with licensed contractors to construct
the project(sec.7044,Business and Professions Cotle:The Contractor's Ucense Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of properly who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
C1 am exempt under Sec. is a P.C.for this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
1 hereby affirm under penalty of perjury one of the following declaration: 7
❑ have and will maintaina of the
cate Labor
Consent the performance of
oftheWorker's Compensation,hthis G /�O Building ` /
as provided for by Section 3700 of the Labor Cotle,for the pedormence of the work for which this ``/ J`
permit is Issuedhave
and. / Seismic
❑ have and will the performance
Workers f the work
Insurance,as required u Section 3700 at /
the Labor Code,for the performance of Policy
work for which this permit le Issued.My Worker's Total ��
Compensation Insurance carrier and Poli number are:
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(Thio aeRlan need not be compleletl If the permit ie for one hundred dollen($100)or lase.) �
I certify that In the performance of the work for which this permit Is Issued.I shell not amptoy
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 mat vial being
forma. installed. If a root is installed without first obtaining an
Date Applicant inspection,1 agree to remove all new materials for inspection.
subject to the Workers'CompeICE TO APPLICANT: l,after nsation provisions of thecale of LaborCode,Exemption,
must forthwou 1ithbComply Applicant understands and will comply with all non point
with such provisions or this permit shall be 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 rotating to building construction.and All rO cOerin%to he of .nor better._ /
hereby authorize representatives of this city to enter upon the above-mentioned property for In. / h
spectlon purposes.
(We)agree to save,Indemnify and keep harmless the Clty of Cupertino against Ilebllltlee,
judgment.,costs and expenses which may In any way accrue against said CityIn conaequance
of the granting of this permit. SI ATURE 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