R-6618 PERMIT R_ 6 618
APPLICATION FOR /'f�"')�-2 CITY OF CUPERTINO NUMBER
REROOF PERMIT IV 35
INSPECTION 7 DIVISION PERMIT EXPIRATION
(408)7773228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS
100 DAYS FROM LAST CALLED INSPECTION.
�
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ It yes–I understand that a Class A
NAME roof assembly is required.
NO ❑ InNal I.C.B.O.&
ADDRESS EXISTING ROOF COVERING
PHONE /— 3 NUMBER OF EXISTING COVERINGS /
CONTRACTOOrs Q
TO BE REMOVED / TO BE RETAINED
NAME
ADDRESS j/ � TYPE OF ROOF COVERING
CITY a ZIP u. r EXISTING -
PHONE _' v� BUILT-UP ROOF ❑
CENSE
NUMBER a{ ` rASPHALT SHING I� 71
LICENSE CONTRACTORS DECLARATION D
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Stuff WOOD SHAKES u z`Q�LJ
7000)of Division 3 of the Bushels and Professions Cade,and my license le In full force
effect. nn /��73/ OODSHINGL JUN 16:11999
License Claes__, Lic.Number (((�/i/
R(S CIF ❑
Date Contractor
OWNER-BUILDER DECLARATION P Po By
I hereby affirm that I am exempt from the Contractors 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 ❑
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor.License Law(Chapter 9(commencing with Section 7000)of Division 3 of me
• 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).):
01,as owner of the property,or my employees with wages as their sola compensation,will do WOOD SHAKES ❑
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Profes.
slon.Code:The Contractor's License Lew does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who tloes such work himself or through his own employees.provided that
such improvements are not Intended or offered for Bala.11,however,the building or improvement
Is sold within one year of completlon,the owner-builder will have the burden of proving that he did 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 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
with a contractoge)licensed pursuant o the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: Aryl /ry"7
C1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building 0
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this ��
permit is Issued. 160
Fl I have and will maintainWorkers Compensation Insurance,as required by Section 3700 of
Seismic
the Labor Co for the pertOrmance of the work for which this permit Is Issued.My Workers Total ` `�
Camps sell surence c nd Policy number era:
Cannot PollcyNo. UOU229 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ ^
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) O r-
1 tarty 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 Call- All roofs shall be inspected prior to any roofing material being
. forma. 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: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pp. P Y P
with such provisions or this permit shall be 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 OfC S1 b class Or better.
hereby authorize representatives of this city to enter upon the obova,meatloned property lot int ��/�
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,caste and expenses which may In any way accrue against said Cly In consequence SIGNATURE OF APPLICANT DATE
oI the granting of this permit.
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