R 6110 PERMIT R_ 6110
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN PERMIT ISSUANCE OR
184)WITHIN FROM
LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL - COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME roof assembly is required.
2 1 J�O o m( fl/ NO E] Initial I.C.B.O.N
ADDRESS � 5 cf fK/,1�r. EXISTING
ZPHONE �i NUMBER OF EXISTING COVERINGS e
CONTRACTOR' /'
,,i c, TO BE REMOVED TO BE RETAINED
NAME
cNazP �R�Zt013 15A� _;e 1561 TYPE OF ROOF COVERING
3r�Vl`-7G 23 J l7 EXISTING
PHONE. L/ z-a� ���I BUILT-UP ROOF ❑
LICENSE
NUMBER 3S tP LI ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
onset. iI(�r_^lY �0 WOOD SHINGLES ❑
License a +" Lid.Number T
4' OTHER(SPECIFY) ❑
Date Contractor
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: A cl o
construct.alter,improve,demolish,or repair any at cure,prior to dance, mqui to BUILT-UP ROOF ❑
applicant for such permit to fila a signed statementfap"fly
ala IIc rsuant�I�I�)hhep s s
. of the Contractors License Law(Chapter 6(comm with 00)of Division a
Business and Professions Code)or that he is ex arefrom and the basis for the I d ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any nt for a permit subjects the apps
e civil penalty of not more than five hundred calls 0).)r CD 100 ❑
C]1,as owner of the property,or my employeeswaga�Feir I rr,�d0d on, WOOD SHAKES
the work,and the structure is not Intended or offerr sale(Sec.7044,Business and ro -
slnsCod o:The Contractors License Law does nptoanownerofpropertywhob a r WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided th t
such Improvements are not intended or offered for however,the bulldIng or Improveme t
Is sold within one year of completion,the owner-bull IRYaIh& 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 Llcenae Lew tloes not OVI E I.C.B.O.REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for each projects
with a contractor(s)licensed pursuant to the Contractor's License Lew, P IDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B 6 P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
1 hereby affirm under penalty of perjury one of the following declaration:
OI have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, _
a3 ovki for by Section 3700 of the Labor Code,for the performance of the work for which this / BuildingIZZ/ 30 TT ^^
permit is Issued. / I D rL $eISrI11C
❑I have and will the performance
Worker's Compensation Insurance,pe required is i by Section 3700 of / 1 ��t 3
the Labor Code,for the performance of the work for which this permit is issued.My Worker's
Compena Ina]�ence�°^le�rantlPolicynumberera: ��� Total
Carrier 1 C YV Policy No.( X3 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed II the permit IS for one hundred dollars($100)or less.) �Q�
I certify that In the performance of the work for which this permit Is Issued I shall not employ z Q ( �l/ y
any person In any manner so as to became subject to the Workers'Compensation Laws of Cali- All roofs shall be inspected prior to any roofing material being
fornia. 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: 11,after making this Certificate of Exemption,you anould become Applicant understand
subject Id the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP and will comply with all non point
with such provisions or this permit shall be doomed revoked kIGNATUR
#AP
1 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 state laws relating to building construction,and 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 termites the City of Cupertino against liabilities,
. of the granting
coats and expenses which may in any way accrue egalrmf said DItY In consequence .
of gran,co onnid permit. CANT DTE
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