R-6662 PERMIT R_ 666
2
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (406)777-9226 PERMIT EXPIRES IF WORK IS NOT STARTED
- - WITHIN 1M DAYS OF PERMIT ISSUANCE OR
1W DAYS FROM LAST CALLED INSPECTION.
� BUILDING ADDRESS - -
L RESIDENTIAL COMMERCIAL OTHER—
OWNER'S
KAZARDOUS E-AREA
NAME S/111-7; - YES' ❑ If yes—I understand that a Class A
roof assembly Is required.
NO ❑ InNel I.C.B.O.#
ADDRESS—i S y G •/1!/� EXISTING ROOF COVERING
PHONE
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S/1 -
NAME G G V2D D(F!N TO BE REMOVED / TO BE RETAINED
ADDREssl TYPE OF ROOF COVERING.
CITYBZIP-5?% • - !'q = it
PHONE yG� ��� - �g BUILT-UP ROOF, .❑
LICENSE• _
NUMBER 9�'Z�Z ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provable;of Chapter g(commencing with Section WOOD SHAKES
7000)of DMelon 3 of the Business and Professlon,Code,and my license Is In full force and -
etect. WOOD SHINGLES
License Claes ---�r' q UP.Number ( / Z O Z -' ❑ "
Dale Contractor 7-$- L / '>f G' �DGc�IUG- OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Conmictore Ucanse Lew for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a pormlt to
construct,alter,Improve,demolish,or repair My,structure,prior to its Issuance,also requires the BUILT-UP ROOF - Elapplicant for such permit to file a signed statement that he Is licensed pursuant to the prodslons
of the Contractors Ucense Law(Chapter B(commencing with Section 7000)of Dlvialbn 3 of the
Business and Potosi Code)or that he Is exempt therafrom al the basis for the alleged ASPHALT SHINGLES
exemption.Any violetlon of Section 7031.5 by any applicant for a permit subjects the applicant to
e cldl penalty of not more than five hundred dollars(5500).):
E]1.as owner of the property,or my employees with wages as their able compensation,will tlo WOOD SHAKES ❑
the work,and the structure is not Intended or offered for able(Sec.7046,Business and Proles.
sions Code:The Contractor's License Law does not eppty to w owner of property who bunds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided Mat
such Improvements are not intended or offered for able.If,however,the building or Improvement
B sola within one year of completion,the owner-bulider will neve the burden of proving that he did OTHER
.(SPECIFY) ❑
not build or Improve for purpose of cele.),
❑I,as owner of the property,em exclusively contracting wlM licensed contractors to construct
the project(Sec.7046,Business and Professions Coda:The Contractors Liceese Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bul Ids or lmprovee thereon,and will connects for ill projects
with a wntractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
El em exempt under Sec. ,B d P.C.for this reeeon
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the folloMng dedaratbn: r�7
❑I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /
parrnit is Isaued. SBISmc
❑ have and wool themaintain Workers f ffie work
for Ineurence,as required su d.My 370001 O 7 G D. /
the Labor Code,for the performance of the work lar whlch'Nle permit Is Issued.My Workers
Comperuhatlon Insurance tbrrler enol Policy number are: Total
Carrier x5�� 11:'1 Y-) Policy N.,7/9—`1_&yz/10 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 �/r+ ^ I
/-t
(This section need not be completed If the permit Is for one hundred dollars($100)or least ` ( //Y 7�
I Canty that In the parformence of the work for which this permit Is Issued,I all not employ
any parson e;any manner so as to become dull to the workers'Compensation Laws of Call- All roofs shall be inspected prior to any roofing material being
torrid. / installed. If. a roof is installed without first obtaining an
Data ^-7/ ua/ Applicant eS4?411 JPO e[¢Ii eg/3 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 provislans of the Labor Code,you must forthwith compty
with such provisions or this permit shall be doemetl revoked. source regulations.
I certify that I have reed this application and slate that the above Information Is correct.I agree
to comply with all city and county ordinances antl state lam relating to building construction,and All roof Coverings to be Class"or better.
hereby authorize representative,of this city to enter upon the above-mentloned property for In-
spection purposes.
(Wa)agree to save,Indemnity and keep harmless the Clty of Cupertino against liabilities,
judgments,costs and expenses which may In any way ecuue against sale City In consequence SIGNATURE OF APPLICANT ' 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