R 6227 APPLICATION FOR CITY OF CUPERTINO NUMBER R- 6227
INSPECTION DIVISION p RM1i ExPIRArION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
160 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS M�('�
_ C)cz-79� • -�^Qn e RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
U \ o . S YES E] If yes—I understand that a Class A
NAME roof assembly is required.
NO C] Initial - I.C.B.O.q
ADDRESS CI3
-\8ll n 1d f f 0-\euC 41_ISA. CH 14 EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S ,�(,, ('
NAME &SS-Qv r t- �[D�1�}•J�Cb TO BE REMOVED TO BE RETAINED
ADDRESS �J TYPE OF ROOF COVERING
CITY a ZIP !�: Ufr\c.&k� A A3 %7 /q 1 a EXISTING
'
PHONE e9cl�I- ^l400 BUILT-UP ROOF ❑
LICENSE ❑
NUMBER 4 3 CC ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION C WOOD SHAKES
I hardy affirm that em Ilceneatl and
Pr provisions of Chapters(commencing with Section
]000)of Division 3 of the Business end Profeealons Cod,and my license le In full force endue
effect. ``_-1`y9T"
(� Zy)� YI WOOD SHINGLES ❑
License Claes C-3 LIc.Number `-'
Date 10-��l-dl� contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION h PROPOSED 1g,7
I hereby aHlrm that I em exempt from the Contractor's License Law for the following reason.
(Sec.70 1.6,Business end Professions Code: Any city or county which requlree a permit to
constructalter,Improve,demolish,or rapalranyatructure,prior Issuance,also requires the I 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 S(commeocing with Section 7000)of Division 3 of the
• Business and Professions Code)or that he Is exempt therefrom and the bask for the alla9etl ASPHALT SHINGLES .
exemption.Any violation of Section 7031.5 by anyapplicant for a permit subjects the applicant to
a civil penalty of not more than five hundred doliare($500).):
El 1,as owner of the property,or my employees with wages as their we,compensation,will WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,BuSlnes as-
slons Cotle:The Contreclole License Law does not apply to an owner who i s or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or throu em a,provl that
such Improvements are not Intended or offered for sale.ll,h w er,the b it impro ant
Is sold within one year of completion,the owner-bullder will et aburd pr ng that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
E]I,as owner of the property,am exclusively contracting wl need s9�(ectyye�c o��r
the project(Sec.7044,Business and Prolesalons Cotle:The r cto� no a7rdoes not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or improves thereon,a hoc IS for such projects
with a contractor(s)Ilceneatl pursuant to the Comractoea Lice Law. PROVIDE MFG R.INSTALLATION SPECS.
01 am exempt under Sec. ,B&P.C.for this reason
Owner � APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DEng declaration:
1 hereby affirm under penalty of perjury one of the ftoowing urefrWo 7,
❑1 have and will maintain a Certificate of Consent to eperforma for Worker's Compensation,hthis q Building s/
pas erm I providedforby Section 3700 of the Labor Code,for the performance of the work for which this / C)— ( 1 ' 0
perms Issued. �r
C)—
;4h and will maintain Worker's Compensation Insurance,as required by Section 3700 of 1 �3 Seismic
-the Labor Code,for the performance of the work for which this permit Is is d.My Warker'e I I O
Compenaatl Inaurencec rentl Policy number are: �� Totel ` ✓ r
°� ua ads -117�b
carrfer � P �ICATEO- policy Na. PERMIT AUTHORIZATION DATE
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION
N
ONINSURANCE O❑
It the ,.
(This section naso not be completed If the permit Is for one hundred dollars($100)or less.) f
I certify that In the performance of the work for which this permit is IseuI shell not employ
any person in any manner so as to become subject to the Workers'Com na Ion Laws of call. All roofs shall be inspected prior to any roofing material being
fornia. _ installed. If a roof is installed without first obtaining an
Date I� \"'l— Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT, after makinbecome
subject to the Workers'Compelnsation previsionis of the Labor Code,yoCertificate of Exemiu mustufo thwlltlh comply Applicant understands and will comply with all non point
with such provisions or this permit shakes deemed revoked, SOUfCe regulations.I certify that I have read this epplicatlon and state that the above Information is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings be .lass"C"or better.
hereby authorize representatives of this city to enter upon the above-mentionedp
(We) roperty for In-
sppurposes.
(We)agree s save,indemnify w entl keep harmless the Clry of Cupertino against Ilabllltles, `�����$
ofjudgments,the gran coats and expenses which may In any way accrue against said City In consequence
•
of granting of this permit. SIUNATURE 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 SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY -