R 6025 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 6025
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
Goc% cvooee ,Q•f
RESIDENTIAL_ COMMERCIAL OTHER
OWNER'S , / HAZARDOUS FIRE AREA
/ ' / a YES ❑ If yes-I understand that a Class A
NAME L.i(_/ roof assembly is required.
NO ❑ Initial I.C.B.O.k
ADDRESS a k-" EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS /
CONTRACTTq S� /,�
NAME C`/.S (1 !4105 �B•Of/' �,l+,l TO BE REMOVED TO BE RETAINED
ADDRESSTYPE OF ROOF COVERING
CITY&ZIP �� Y 'dx / /(A( r�u EXISTING
PHONE
� � 33 950'3/ E BUILT-UP ROOF
LICENSE
NUMBER J ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby affirm that I em licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of thetic Business and er provisions
Code,and r 9 license is n full lone and
effect. (�a�� G,,.�,(^/
License Class=-.L�- Dc.Number ( / 6--A WOOD SHINGLES ❑
Dale Contractor
OTHER(SPECIFY) ❑
OWNER tr DECLARATION PROPOSED Q
I hereby affirm that the Conam exempt from the Contractors License Law for the finsafollowing reason.
(Sec.7031.5,Business and demolish,
at re Code: Any city or county white requires a permit to
conaVantforalter,u improve,to file aSigned statement
any structure.Is licenseor to Issuance,also requires the LT-UP ROOF ❑ /�/
applicant for such permit to file a signed r 9(comm that g Ishcena o 7000)of
the provision
of me ss and Contractor's License Law(Chapter 8(commenting ereh Section 7000)of Dfor the 3 0l ih �l,l__
Business end Professions Code)or that he la exempt therefrom and the basis for the all D Aijll& S
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant t a
a civil penalty of not more than five hundred dollars($500).):
❑l,as owner of the property,or my employees with wages as their sole compensation,will d (sf.WOO� ❑
the work,and the structure Is not Intended or offered for eels Sec.7044,Business antl Profs J I+ 1 Siena Cotle:The Contractor's License Law does not apply to an owner of propety who bulitle rWOOD Improves thereon,and who does such work himself or through his own employees,provided ih such improvements are not Intended or offered for sale.IL however,the building or improveme tIs sold within one year al completion,the owner-builder will have the burden of proving that he it B OTHER ❑
not build or Improve for purpose of sale.), Y
❑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 �/��yy'Q_(/^
With a centexem(t)licensed pursuant to the Contractors License Law. PROVIDE MFGR. INSTALLATION SPECS.l e&c�
❑Pam exempt under Sec. ,B 8 P.C.for this reason
Owner Dale
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, BUlldjn
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this �- / ��
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 Issued.My Workers
Compensa ..n Insurance carrier andQ�P(Yyn mbara/rp: L Total 1�•'�g /0
Carrier /��/, i//plicyNo.;J,�����/`s`"`� �f PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N •�`�7�� ^%� ^��
(This section need not be completed It the permit Is for one hundred dollars($100)00)or less.) V (y r
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 Cali. All roofs shall be inspected prior to any roofingmaterial being
fornla. installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: II,after making this Certificate of Exemption,you should become
subject to the Workers'Compensation pprovisions of the Labor Cotle,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit GhYte 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 stale laws relating to building construction,and All roof coverings to be class"46brbetter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes,
jut;g(We)agree to Gave,Indemnity and keep harmless the City of Cupertino against liabilities,
menls,coals and expanses which may in any way accrue against said City In consequence
. of me graining of this permit. SIGNATURE 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 SHALLBE PROVIDED FOR INSPECTION
OFFICE COPY