R 6107 APPLICATION FOR CITY of CUPERTINO NUMBER R- 6107
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 r / x
IIS LU(.'I' l.� RESIDENTIAL` ` COMMERCIAL OTHER
Ow FRS ( ^ HAZARDOUS FIRE AREA
5�a C1 GSI i �ISX VES ❑ If yes-I Understand hat a Class A
NAME // I' 'W,,, r"/ )"'-/'I f•,,,T—\- roof assembly is required.
ADDRESS6 l�" 5' f' ,� C'IYIA?L G� NO ❑ ROOF
I.C.B.O.B
�J/�e EXISTING ROOF COVERING
PHONET t L/4) Z� �j�Q NUMBER OF EXISTING COVERINGS
CONTRACTO
R'S (Q C
NAME ` ,P "C\If_," I f P f`Ic J L/ %CT5 TO SE REMOVED �J TO BE RETAINED
ADDRESSZP� �1�� n _I�J C_ `,�A`(I E 9Sr/ TYPE OF ROOF COVERING
EXISTING
PHONE d I / 7 I� . / BUILT-UP ROOF
LICENSE
NUMBER Zi✓ / ASPHALT SHINGLES ❑
LICENSEDCONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Cotle,and my license Is In full force and
enact. �\ WOOD SHINGLES E]License ClasO- e Z..O LIC.Number 72 ZQ v
Data gY contract $ OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF 3a"'
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions f
cl the Contractors License Lew(Chapter g(commencing with Section 7000)of Division 3 of the
• Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500),):
❑I,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-
sons ImproCotle:The,anwho desLicenseuch Low does not apply ganowner of property who builds WOOD SHINGLES ❑ ��
Improves thereon,end who does such work himself or through his ow el
such Improvements are not intended or offered for sale.II,he e ulld�lF,gp�y Improve nt
Is sold within one year of completion,the owner-builder will hav umen NdrdvlM that h m OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.). !u�``"�
❑I,as owner of the property,em exclusively contracting wit a ad con CIO to construct
the project(Sec,7044,Business and Pro feeelona Code:The C for a_LicenBe.!{avydo,s�p�g PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or imp roves thereon,an It C08 or c r<dlsa�Zttss''
with a contractor(a)andlicensedSe pursuant to the Contractor's Licen aw, PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,B 8 P.C.for this reason
ownerOMPENSATION DECLA
WORKER'S to LICATION DATE VALUATION PERMIT FEE
C
hereby affirm under penalty of perjury one of the followingIfon: -7 SZ - c ,
❑ have and will maintain 37 a of thelca b of Consent or to eeMorma for Workers Compensation, L •J BUlldln —/b—
aemitIsIsfor WSection 370001ihaLaborCode,for the performance of the work for which 1hle ��) ^ g (� fyh
permit le Issued. 9 Seismic �/�
❑ have and will the maintain Workerperformance
Compensation the work
Insurance,as required by Section 3700's (� �y r� � ® ,A
the Leber Code,for the pedormence of the work for which this permit Is Issued.My Workers 'I—16` U Total
Campo atlan Ina renpe terrier end Policy nu bar ere: v
Ceras Policy No.D329 7 (; PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTI N FROM WORKERS'
COMPENSATIONIN URANCE N.C.❑ -}y�r2,. p�
(This section need not be completed If the ermlt Is for one hundred dollars($100)or less.) V c V '^
I certify that In the performance of the r which this permit Is ue hall not employ 7 any person In any manner so as to beco suble m the W)rkers' pen=ab Laws of call All roofs shall be inspected prior to any roofing material being
fornoa. installed. If a roof is installed without first obtaining an
DatR')(0 ) Appll<en 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 previsions of the Labor Code,you must forthwith comply Applicant understands and will Comply with all non point
with such provisions or this permit shelObe 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 state laws relating to building construction,and All roof coverings to be class" or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
g(We)agree to save,indemnify and keep mumleea the City of Cupertino against liabilities,
oltlhaMonte gramiCost.ng of tand his expen es which may in any way accrue against said City In consequence 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
__ OFFICE COPY