R 6210 PERMIT R_ 6 210
APPLICATION FOR CITY OF CUPERTINO NUMBER
R"
PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
• WITHIN 180 DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS
180 DAYS FROM LAST CALLED INSPECTION.
C
I I V e(a Q G�Q. RESIDENTIAL COMMERCIAL OTHER
OWNER'S 1 HAZARDOUS FIRE AREA
..7 I � YES ❑ If yes—I understand that a Class A
NAME 1 tel/ =1 assembly Is required.
NO ❑ Initial I.C.a.O.I
ADDRESS � -" �} r I �/ Q e41 EXISTING ROOF COVERING
PHONE / ——( Z NUMBER OF EXISTING COVERINGS
CONTRACTOR'S \I�
NAME- TO BE REMOVED TO BE RETAINED
ADDRESS. /D 2 f_ r S RS.f z TYPE OF ROOF COVERING
CITY B ZIP L/ _
EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE ✓ - ❑
NUMBER ASPHALT SHINGLES
LICENSED TRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES
]000)of Division 3 of the Business endd Professions Code,and my Ilcens is In full!ores and
effect. � 3 Q
WOOD SHINGLES
License Class G' Lic.Number
Date �Q Contractor rdR S OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATIONQ P
I hereby affirm that I am exempt from the Contractor's License the to win son.
IS
7031.5,Business and Professions Code: Any city or count h requIraa a permit to ))
construct,alter,Improve,demolish,or repair any structure,prior to l an Was the J UILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licen purau6rhJo the p/Ovy0 -
of the Contractor's License Law(Chapter a(commencing with Se 7000)of Olvisi 30f tHA4[1p
• Business and Professions Coca)or that hails exempt therefrom and the basis for ins site g SPHALT SHINGLES �LrJI
exemption.Any violation o1 Section 7031.5 by any applicant fora appIt subjects the applicant to
e clv❑II penalty of not mor
e than�Iva h�ntlr�tl dollars($5008.): Ol/ WOOD SHAKES ❑
I,as owner of the ro ert or my employees with wages as often,will do
the work,and the structure Is not intended or offered for sale(Sac.7044,Bus
'sions Coda:The Contractors License Law does not apply to an owner of property who bu 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.If,however,the building or Improvement
Is sold within one year of owlet on,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 bullds or Improves thereon,and we Contracts for such projects
with a contmctons)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following decfaratlon: �J
❑I have and will maintain a Certificate of Consent to selNnsure for Workers Compensation, Q l ^ A. t Building
as provided for by Section 3700 of the Labor Code,for the performance of thework for which this (�/�
permit Is Issued. 0 Q C - Seismic _�
❑ have and will the performance
Worker's Compensation work fon Insurance,e3 required Is i by d.My 3700 of
the Labor Code,for the pedormenca of the work for which this permit IS issued.My Workers � ' �-z
Compensation Insurence ceryl r entl P011cy nu(mber are: Total j( . 0
Carrier J�g�L�Ut/ICl POIIcyNo.l U�� 3 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed it to permit 16 for one hundred dollars($100)or lase.) ` /`
I certify that In the performance of the work for which this permit Is Issued,I shell not employ
any Per In any manner so as to become subject to the Workam'Componsatmn Laws of Cell- 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.
subN�toE a WorkereTO CC mpef,after naetlon provisionls ofthelcate of Laborr Code,you mustuforthwiitthbecome
comply Applicant understands and will comply with all non point
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,l agree ,����-��
to Comply with all city and county ordinances and state laws relating to building construction,and 1AFr00r0 verings to be class Gor better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in. f�
spa tion(We)
purposes. r
(We)agree to save,Indemnifyexpenses
w and keep harmlessay to City of Cupertino said city
y -------------
of
--t liabilities,
I
ofthe gran costa and expenses which may In any way accrue against said Ciry In consequence
attnegrentingoimiapermu. --SIC'NATUREOFAPPLICANT DATE
�- PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP—DATE-
TEAR
NSP. DATETEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY