R 6400 (3) PERMIT .
APPLICATION FOR CITY OF CUPERTINO NUMBER R" 6400
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (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 /✓,,p
C /00 IC, T-0�K-/�j v2r, RESIDENTIAL COMMERCIAL OTHER
OWNER'S �/�� '/}�5 / / N/ HAZARDOUS FIRE AREA
NAME �� "ter— " ' • ` `^�"'� NO /Irayof assembly streqund iredliaeta Class A I.C.B.O.M
ADDRESS 1105�� �Sp': EF-g / A (J� Co
LY EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR /
NAMEr��SU-SI.LJA'��L -Zi TO BE REMOVED TO BE RETAINED
ADDRESS ,/ TYPE OF ROOF COVERING
CITY&ZIP O3 �UCC1�l�`-7!'r+`Y ASI AX
Q^ EXISTING
PHONE/u 3 Cy � �t ^ ��? BUILT-UP ROOFLICENSE
/
NUMBER 8 3 3 AS ALT SHINGLES--. _ [�
LICENSED CONTRACTORS DECLARATION C]
hereby affirm that em licensed under provisions of Chapter 9(commencing with Section D SHAKES h
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and I
effect. ES L
License Class ` —3 Lic.Number �3] .3-n w MAR ❑4 X999
Data ^��—` Contractor TE$US •+'��mc-� 2 SPEC 2❑
OWNER-BUILDER DECLARATION PROPOSED/ s
I hereby affirm that I am exempt from the Contractor's License Law for the following reason. y
(Sac.7031.5,Business and Professions Code: Any city or county which requires a permit to �'"^--.---..-
construct,alter,Improve,demolleh,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's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
• Business and Professions 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 five hundred dollars($500).): WOOD SHAKES ❑
❑I,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-
sions Code: The Contractor's License Law does not apply to an owner of property who bunds or WOOD SHINGLES El
thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.II,however,the building or Improvement
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER (SPECIFY) ❑
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 Contractor's 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 Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. .B 8 P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of the following declaration: /q z`
1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, xe O,x.� Building L
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this l/J� v
permit Is Issued. Seismic so
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of ,,./
the Labor Cotle,for the performance of the work for which this permit Is Issued.My Worker's /, S O
Compensation Insurance carrier and Policy number are: 41 TO
�yy/2 PolicyNo.� l3� PERMIT AUTHORIZATION DATE
Carrier 651 e
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE N.C.I] O
(This section need not be completed If the permit Is for one hundred dollars(S1 DO)or less.) 3^
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
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 material being
fornix. installed. If a roof is installed without first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
NOTsubject llx thee WorrkerTO sC APPLICANT.
do promakivisionls of theicate of Laborr Code,you must forthwiitthbecome
comply 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 correctI agree
to comply with all city and county ordinances and state laws relating to building construction,and
All roof coverings to be class' or better.
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 $ ATURE OF APPLICANT DATE
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IWPROG
INSP.-!LE- 07r DATE 3 —� 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