R-6615 APPLICATION FOR
CITY OF CUPERTINO NUMBER RPERMIT 6 615
�j INSPECTION DIVISION PERMIT EXPIRATION '
REROOF PERMIT _ /�02 (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
t ✓(1� WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING GA1S
go
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME_aLYES E] It roof assembly s requis-I understand red.
Claw A
r�n NO E, Initial I.C.B.O.N
ADDRESS �ti./ h.Q.J EXISTING ROOF COVERING
PHONE xJ /- 2,13 Q NUMBER OF EXISTING COVERINGS /
CONTRACT
' TO BE REMOVED TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
clTv a zIP ny/ /9 / EXISTING
PHONE 6�U /3&2L '�/1 // BUILT-UP ROOF - ❑
LICENSE
NUMBER bc;2,3l-731 ASPHALT SHIN rr-T1
LICENSED CONTRACTORS DECLARATION [�
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKE D D
7000)of Division 3 of the Business and Professions Code,and my license is In full force and f-1�
effect. C 39 2a-�3� WOOD SHINGL JUN 1 6y(7p(�
License Class Lie.Number 1JJJ
Date ContractorOTHER(SPECI ) ❑
OWNER-BUILDER DECLARATION ED By
I hereby affirm that I em exempt from the Contractor's License Lew 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 BU QQF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Lew(Chapter 9(commencing with Seclion 7000)of DMelon 3 oilhe
• 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 far a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES
❑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 sale(Sec.7044,Business and Profes-
$lona Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.ll,however,the building or improvement
Is sold within one year of completion,the ownarbuilder wl 11 have the bu men 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 contractogs)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
C]I am exempt under Sec. .B 8 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: ��^J//(�
❑I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, Building _lZ'"r—
asprovidedforbySection3700oftheLaborCode,for the performance of the work for which this /}]'� 1. 50
permit is Issued. �O• ov Seismic
❑I have WIV will maintain Worker's Compensation Insurance,as required by Section 3700 of /
the Lor d ,for the pe anca of the work for which this permit Is Issued.My Workers %9g
Cam s Insurance Carrie end Policy number are: X/y �( Total
carr kcy No.Na-0 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed It the permit Is for one hundred dollars(5100)or less.)
I certify that In the performance of the work for which this permit Is issued,1 shall not employ
any person In any manner so as to become subject to the Workers'Compensation Lawa of Cali All roof^shall be inspected prior to any roofing material being
fortis. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
me
subject to the WorrkerCE TO ls'Compen,after sation ion provisionls of tthelcate of Labor Coo,Exemption,
musufo thwshoullithb comply Applicant understands and will comply with all non point
with such provisions or this permit shairbe deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information is correct agree
to comply with all city and county ordinances and stets laws relating to building construction,and All r f covenricIsto be class "or better.
hereby authorize representatives of this city to enter upon the above-mentioned property far In- _
spection purposes. ,
(We)agree to save,Indemnify and keep harmless the City of Cupertino againstIlabilities,
judgments,costs and expenses which may In any way accrue against said City Inconsequence SI NATURE OF APPLICA T 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY