R-6563PERMIT R_
6 5.6 3
APPLICATION FOR CITY OF CUPERTINO NUMBER
' INSPECTION DIVISION
REROOF PERMIT (408)M-.3228 � PERMIT EXPIRES IF WORKS NOT STARTED
" - WITHIN 130 DAYS OF PERMIT ISSUANCE OR
130 DAYS FROM LAST CALLED INSPECTION.
BUILDI/NG ADDRESS
C
/D(Y�/ GIBS
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RESIDENTIAL COMMERCIAL OTHER
OWNER'S
- HAZARDOUS FIRE AREA
YES ❑ If yes- I unden#ard that a Ctase A
NAME '• r. / /
cool assembly is required
NO ❑ Initial I.C.B.O. A
p//•
5-_/
ADDRESS
tog'.246
NUMBER OF EXISTING COVERINGS
PHONE
- -_ •
TOBEREMOVED I TOI BE RETAINED
MTRAC$
A44/n.
NAME
ADDRESS —7,/ n G�
`C'V?
_ TYPE OF ROOF COVERING
CITY 8 ZIP / ✓
EXISTING
�ri -�-ZZ4-5%DS
9
PHONE
BUILT-UP ROOF .
NCENSEUMBER f7 5� GDC
NUMBER 6 ✓(J
ASPHALT SHINGLES ❑ .
' LICENSED CONTRACTORS DECLARATION
hereby that em under of Chapter B (commenting with Socronand
WOOD SHAKES
ison Business lessors
7000) pl Diviefon 3 0l the Business entl Proleeekxu Cade, and rtry license Is In lull force entl
effect
��
WOOD SHINGLES ❑
License
License Clea Lk. Number'
4 41 /�
OTHER (SPECIFY) ❑
Date Canfre
OWNER -BUILDER DECLARATION
I hereby allirm that I am exempt from the Contractors License Law following reason:
PROPOSED
(Sec. 7031.5, Business and Proleaelone Code: Any city or county which requires a permit to
construct, sitar. improw, dem or repair any stnxture, prior to Its sa- nce, also regdrss the
BUILT-UP ROOF ❑
applicant for such permit to file a eignad statement that he Is licensed pursuent to the prodsone .
of the Contractors License Lew (Chapter g (commendnp with Section 7000) of Division 3 of the
Buslnese and Professions Cade) or mat he le exempt therefrom and the baels for the alleged
ASPHALT SHINGLES ��, �� k
n exemption. Any violation of Section 7031.5 by any applicant for a permit subjects me applicant to
/ 7
y
a civil perulty of not more than five hundred dollars (5500).):
1, the Meir do
WOOD SHAKES ❑
❑ as owner of property, or my employees with wages as "a comperuafion, will
the work,and the structure is not Intended or offered for sale (Sec. 704x, Business and Prattle -
'
alone
alone Code: The Contractors License Law does not apply to an owner of property who builds or
WOOD SHINGLES ❑
improve thereon, and who tlaes such work himself or through his awn employees, provided that
Much Improvements are not Intanrded or offered for sale. If, howewr, the building or Improwment
y�
Is sold within one year of completion, the owner -bulkier will hew the burden of proving that he did
OTHER(SPECIFY) ❑ F-- I
not build or Improw for purpose of este.). -
I]I, as owner of the property, em exclusively confracdng wlfh Ikenaed contractors to construct
the ProJect (Sec. 7044, Busineee and Proleeslons Code: The Contrectore License Law dove not
Zwappy to an owner who builds Improves thereon, for
PROVIDE I.C.B.O. REPORT NO.
of property or and who contracts such prolecla
with a ccntrectogs) ncensed pursuant to me Contractors License Law.
PROVIDE MFGR. INSTALLATION SPECS.
C]I am exempt under Sec. ,B S P. C. for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury are of the knowing declaration:
❑ I hew and will maintain a Certificate of Consent to self-Inaure for Workers Compensation,FA4�Q�
BUIId
m g
as provked for by Section 3700 o1 the Labor Code, for the perlormence of the work kr which this
permit Is Issued.
� OJ �
m C 70
❑ I haw and will maintain Workers Compensation Inwence, as required by Section 3700 of
the Labor Code, for me Performance of the work for which rob permh is Issued. M] Workers
I
comp `n°}�d suuren�ce,unier and Policy number are:
?
cerrle't/ " "^" '" '�� Poky Na
PERMIT H T
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
—/
' (This section need rot be completed II the permit b for one hundred dollars (S 100) or lose.)✓-',�
L' p
I certify that In the performance of the work for which role permit Is leased. I shell not emWoy
any In any manner so as to become subject to the Workers' Compensation Laws of Call-
All roof^ Shall Sp t d ny r material being
person
lorikH' -
prl g
installed. If a i t obtaining an
Data S �y'- �' S Appficam -
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should become
Applicant understands and will with all non int
pp comply p Y
subject to the Workers' Compensetlon provblons of the Labor Code, you must forthwith comply
with such provisory or the perp t shelgbe deemed revoked.
Source regulations.
I certify mat I hew read this application and sate that me above Information a correct. I agree
to comply with all city and county ordnences and sate laws relating to bullding construction, and
All rverings to be class "C"or better.
hereby authorize reprssenatiws of this city to enter upon the ebove.mendoned property for In-
epectlon purposes.
(We) agree to saw, Indemnity and keep hannleea the Ctiy of Cupertino apelnet Ileblllfbe,
jutlpmens, toes and e.pan.- which may In any way accrue against sold City In consequence
$I NATURE OF LIC T DAT
- of the soling of this permit.
l PRE -INSPECTION:.
PLYWOOD:
1 ROGRESS:
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