R 6166 APPLICATION FOR CITY of CUPERTINO PERMIT
U sER R- 6166_
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.
UILDING
� B���os`ADDRESS7
RESIDENTIAL (COMMERCIAL OTHER
owNER'S1/�1HAZARDOUS FIRE AREA-
VES
NAME l fiL IY.L[ I, - El1111,assembly s req Tired. Class A
NO Initial I.C.B.O.8
ADDRESS 5 a- WL -e� EXISTING ROOF COVERING
PHONE 44 O C4 1_ NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S - ,
NAME L0 S 'rQ s �• TO BE REMOVED TO BE RETAINED
ADDRESS /fJee TYPE OF ROOF COVERING
CIN 8 ZIP APdoC.(� 4?47) EXISTINGI_�
PHONE 33 Taj
���� � BUILT-UP ROOF ❑
LICENSE
NUMBER12iLICENSED ASPHALT SHINGLES El
DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 0(commencing with Section WOOD SHAKES
7000)of DIVISIori 3 of the Business and Professions Code,and my license le In full force and
effect. WOOD SHINGLES
License Class C 39 Lid.Number
Date Conlractor
OTHER(SPECIFY ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby allirm that am exempt from the e: Any
city License Law for the following meson.
(Sec.70315,Business and Professions Sp Code: Any city or county which requires requires permit to
constapplic tit alter,Improve,to file siorrepeatenystructure,prior to Its leausnce,alsoeprovithe BUILT-UP ROOF
applicant for such permit to flaw a signed statement that he Is licensed pursuant to the provisions the
of the Contractor's Professions
Lew(Chapter 8(commencing with Section 7000)of for the 3 of the
Business and violation of Code)or thet he Is exempt therefrom for
and the basad for the alleged ASPHALT SHINGLES
axempllen.Any lty of oat more
than
ionfive hundred
by any sppllc m la a permit subjects the applicant to
a civil penalty of not more then Ilve huntlretl tlollers(SB
El 1,as owner of the property,or my employees withsae R sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered y uqle(Sec.7R44„�Business and Profes.
sion.Code:The Contractor's License Lew tloee not p ly,o on oytn44r9 p P ty who builds or WOOD SHINGLES ElImproves thereon,and who does such work himself Jlhf(ough hISwiRir ployee , ovlded that
such Improvements are not Intended or offered for however,the b Idling o ment
Is sold within one year of completion,the owner- )Qarwill Navy the burns of pro that OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively ontractingwith ce�jed�ontmdors to -
the project(Sec.7044,Business and Professin ode:The Contra"Star Li;ppAg Lew e t PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or lm re, hereon,and who contr uc �r is
with a contractor(a)licensed pursuant to the It 'a's License Low. O PROVIDE MFGR. INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for I aeon
lif
ownerWORKER'S COMPENSATION DECLARATIO APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the fallowing declaration: %
❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building
/
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is Issued Seismic
E)1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of ���
the Labor Code,Mr the performance of th work for which this permit Is Issued.My Worker's �`
comp n Insurance cprrler end Poll u er are: _ a 7 9ca Total
Carrle3m, arlwif �yNo.�9 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WOR RS'
COMPENSATION INSURANCE N.C❑
(This section need not be completed If the permit Is for one hundred dollars sl 00)or lees.)
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 roofing material being
torrid. installed. If a roof is installed without first obtaining an
DataApplicant 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
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pp comply p y with all non point
with such provisions or this permit shell be doomed 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 covert ngs to be class 10 or better.
hereby authorize representatives of this city to enter upon the above-menta0nad property for In.
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,•
judgments,costs and expenses which may In any way accrue ageanst said City In consequence
of the granting of INS permit. SI URE OF AFPLICANT 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 -