R 6096 PERMIT R_ 6096
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF.PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL �<COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA .
/ iYES ❑ If yes—I understand that a Class A
NAME LA40o �' al a L I ?V4 roof assembly is required.
J-
NO ❑ Initial I.C.B.O.N
ADDRESS Lf C1 SQL,-9�. t SJ-' EXISTING ROOF COVERING
PHONE CSO - —( � 3 - NUMBER OF EXISTING COVERINGS Z
CONTRACTOR'S /�
A 1 go C41 a _ TO BE REMOVED _TO BE RETAINED
NAME 'K,./ Y�
ADDRESS ' TYPE OF ROOF COVERING
CITY&ZIP / Lit
t 9 Lu h�'�7 C 6,-_ EXISTING
/�
PHONE 70d 01601 G0)C0Z BUILT-UP ROOF ❑
LICENSE ^
NUMBER / / ,j ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES
]000)of Divlelon 3 of the Business and Professions Code,and my license is in lull force and
effect. C-39 WOOD SHINGLES
License Close Uc.Number
Data & Cantrector VYI Y..✓'y{ q�p� OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requlrn.—Ift In
construct,alter,Improve,demolish,or repair any structure,prior to Its issuance.al oregmrest eQ BtJILT- OOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to rovl4lo II JI
of the Contractor's License Law(Chapter g(commencing with Section]000)of D 3 0l
• Business and Professions Code)or that he Is exempt therefrom and the basis t euegatl ASPH SHINGLES Q�
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects t Ilcant to
e civil penalty of not more than five hundred dollars($50D).): (p��
❑I,as owner of the property,or my employees with wages as their sole compo tion, Ill Fle� 1 ) AKES ❑
the work,and the structure Is not intended or offered lar sale(Sac.7044,Buslne ntl Profea
cions Coda: The Contractors License Law does not apply to an owner of proper o builds or WOOD INGLES
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 o vement
Is sold within one year of completion,the owner-builder will have the burden of
p ECIFY) ❑
not build or improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec,7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law. OVIDE MFGR.INSTALLATION SPECS.
❑ em exempt untler Set. ,B&P.C.for iM1le reabon
Owner Date APPLIDATE 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 selbinsure for worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this V
permit Is issued. Seismic
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit Is^lssuetl.My Worker's yT
Componsatlo InAsurlan�c�ce�rr'ixm.e�ntl�P,o/�cy number are; r�p/1�QQ 1o6'Y-. . Total
Carrier '3"�'-1 T'� r `''•"/ Policy No. -( r Tl PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.0)] v
(This section need not be completed If the permit to for one hundred dollars($100)or less.) - alq {x�J'[_ Kr O
I certify that In the performance of the work for which this permit Is issued, shall not employ
any person In any manner so as to become subject to the Workem'Compensetlon Laws of Call. All roofsshallbe inspected prior to any roofing material being
tornia. 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: II,after making this Certificate of Exemption,you should become Alit understands will
subject to the Workers'Compensation rovlslons of the Labor Code,you must forthwith comply ply with all non point
with such provisions or this permit shalPppcanunerstans anm
be deemed revoked. source regulations.
1 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 aingst be clan 'C" rbetter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments.costs and expenses which may In any way accrue against said City In consequence
. of the granting of this permit. SI RE p 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