R-6609 PERMIT
APPLICATION FOR /J ^���777 CITY OF CUPERTINO NUMBER R- 6609
/L,- _/•/' INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT C/ !!TT / (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
180 DAVS FROM LAST CALLED INSPECTION,
BUILDING oADDRESS
S�
- RESIDENTIAL COMMERCIAL OTHER
OWNER'S ///�, / HAZARDOUS FIRE AREA
NAME_/./0,A",? • "' .• YES ❑ If yeas I understand is req that. Class A
roof assembly Is requited.
S.
Q� (Y •(� NO [:jInitial I.C.B.O.g
ADDRESS S
ZSO . �. w7a " EXISTING ROOF COVERING
PHONE .SD c I: 330 NUMBER OF EXISTING COVERINGS /
CONTRACTOR d
NAME—
ADDRESS
AME 70 BE REMOVED / TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY a ZIP – EXISTING
PHONE— ,) BUILT-UPR Q ❑
NUMBER LICENSEa a�3/ ASPHALT S Cl LE� �]
LICENSED CONTRACTORS DECLARATION 11
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Se WOOD SH `S J UPl 1 6 19
]000)of Division 3 of the Business and Professions Code,and my license Is In full force
effect' WOOD SH GLES
License Class Lid.Number �� /
0
e'. OTHER ❑
Date Contractor
OWNER-BUILDER DECLARATION P
hereby affirm that em exempt from the Contractor's or county
Lew for the browing reason.
(Sec.7031.5,Business and demolish,
or rep Code: Any city or couny wNch re,also requires permit to
constructor such prove,ermit t lifea sigedstaeny mentrthate,prior toils issuance,to
the BUILT-UP ROOF ❑
W i ld Co for such permit a Ills a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Lew(Chapter 9(commencing with Section]000)of Divisionthe 3 afire
•
exemption.
and Professions f Code)or that he is exempt therefrom and the jbasisis for the alleged ASPHALT SHINGLES 0/
axemptlon.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).): WOOD SHAKES El
I,as owner of the property,or my employees with wages as their sole compensation,will do
the work,and the structure is not Intended or offered for into(Sec.7044,Business and Fields-
sons Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES El
thereon,and who does such work himself or through his own employees,provided that
such Improvements are not intended or offered for sale.If,however,the building or improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not bulld or Improve for purpose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Coda:The Contractor's 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 contractors)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
Q I am exempt under Sec. ,B 5 P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: (�
I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building l(�m
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 2 /y+/�/
permit is issued. /,5,/ %O'er S81SmIC /• O
I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Cotle,for the performance of the work for which this permit Is Issued.My Worker's
-the
n Ins bncwcarder 5 olicy number are: Total
Carrier /�i � %y���/� �PolicyNo. ��4 `2�S PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ($1 DO)
o
(This section need not be completed if the permit Is for one hundred dollars(5100)or IeseJ l
I certify that In the performance of the work for which this permit Is issued,I shell not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of Cell- All roofn shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,after making this Certificate of Exemption,you should become
subject I.the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shalrbe deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information Is correctI agree
to comply with all city and countyordinances and state laws relating to building construction,and All of coverings to b class" "or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in. `
spection purposes, l�
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costa and expenses which may in any way accrue against said City In conaequenca SIGNA PLICAN DATE
of 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY