R 6167 PERMIT R_
APPLICATION FOR CITY of CUPERTINO NUMBER 616 7
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 // /�/ (/.
llow G[ // V� v 9�'O/ RESIDENTIAL COMMERCIAL OTHER
OWNER'S / HAZARDOUS FIRE AREA
NAME___ {�� Q L VES ❑ If yes—I understand that a Class A
U roof assembly is required.
NO ❑ Initial I.C.B.O.a
ADDRESS S EXISTING ROOF COVERING
PHONEq `7 NUMBER OF EXISTING COVERINGS
CONTRACT R'S /�J — / D / y
NAME d.,Lz / TO BE REMOVED X - TO BE RETAINED
ADDRESS D X n TQ / TYPE OF ROOF COVERING
' CITY&ZIP f-6-2
/� (� EXISTING
PHONE _ �vIy� —/ Cg
/ V.� BUILT-UP ROOF ❑LICENSE
-
NUMBERCEN ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION /
hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑
7000)of Dlvislon 3 of the Business and Professions Code,and my license Is In full force and
effect.
License Class Uc.Number WOOD SHINGLES ❑ /
Date Contract OTHER(SPECIFY) ❑ _
OWNER-BUILDER DECLARATIONPROPOSED --,-•-------'—•-
I hereby affirm that I am exempt from the Contractor's License Law for the following reason. �'as
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to a
construct,alter,improve,demolish,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 8(commencing with Section 7000)of Division 3 of the
•
Business and Professions Code)or that he Is exempt therefrom antl the basis for the alleged ASPHALT SHIN �$ 86t 0 'leo
6
exemption.Any vlolatlon of Section 7031,5 by any applicant for a permit subjects the applicant to U
a civ11 penalty at not more than five hundred dollars($500).): �' a
C]1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes. I�
alone Code:The Contractor's License Law does not apply to an owner of property who builds or
Improves thereon,and who does such work himself or through his own employees,provided that WOOD SHINGLE
such Improvements are not Intended or offered for sale.It,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(e)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
C31 am exempt under See. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, L° BUlldln ,
eermitI Is for by Section 3700 of the Labor Code,for the performance of the work for which this /)� g
permit lav and `I/ Seismic
❑ have and wool maithe performance
Worker's Compensation the wokfor which this as required by Section 3700 of
the Labor Cotle,for the performance of the work for which Ihla permit Is Issued.My Worker's
Compens n Ineurencgcarrler an Ilcy number re' Total IV
Carrier Pl� �'�T cy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORK PS� Is
COMPENSATION INSURANCE
(Thio section need not be completed If the permit IS for one hundred dollars($100)100)or less.)
1 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 Workam'Compensation Laws at Call. All r s shall be inspected prior to any roofing material being
forma. 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: If,after making this Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shallbe deemed revoked. source regulations.
I certify that I have read this application and stale 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 coverin O s"C' or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against Ilebllltles,
judgments,costs and expenses which may In any way accrue against said Clly In consequence
• of the granting of this permit. ATURE OF APPLICANT DA E
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION .
OFFICE COPY