R 6224CJ
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OFFICE COPY
PERMIT R_ 6224,
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777 -3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S -
HAZARDOUS FIRE AREA
S�LV'GY1
YES ❑ If yes - I understand that a Class A
NAME :\ G X h 0 V\
roof assembly is required.
NO ❑ Initial I.C.B.O. p
ADDRESS -- 1036 - /'f \?\ V c \JP a
EXISTING ROOF COVERING
PHONE is — \"� I 1
NUMBER OF EXISTING COVERINGS '1
TO BE REMOVED TO BE RETAINED
CONTRACTOR'S
NAME Z q.LT`x�vLr� C, r`�"C4.� -�1 Y'+Ca - 1'h L
f
ADDRESS
CITY &ZIP i Uw klc-S SCGY. F'^�'J C,' sxci
TYPE OF ROOF COVERING.
EXISTING
\,A 06 ' `L1 , —CIL oo 0
PHONE
BUILT -UP ROOF
LICENSE
NUMBER fj 755
ASPHALT SHINGLES'
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8 (commencing with Section
WOOD SHAKES
7000) of Division 3 of the Business antl Professions Code, antl my license Is In lull force and
anecL
License Class 'h4 Lic, Number S �'��-�
WOOD SHINGLES
KIZO
Date- 41, °s� contractor Vic+- &Z'M -ke'1 V'O Kk �M �
OTHER SPECIFY
( )
PROPOSED
OWNER- BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Lew for the following reason.
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct, altar, Improve, demolish, or repair any structure, prior to Its Issuance, also require& the
BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law (Chapter B (commencing with Section 7000) of Division 3 of the
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
e civil penalty of not more than five hundred dollars ($50l
❑l, as owner of the property, or my employees with wage as their sale compensation, will do
WOOD SHAKES ❑
the work, and the structure Is not Intended or offered for s e`(Seg. 7044, Business and Pales-
alone Code: The Contractor'& License Law does not apply ow f property who buhd or
Improves thereon, and who does such work himself or thr Is own a ees, provided that
WOOD SHINGLES ❑
such Improvements are not Intentletl or offered for solo, ever, th r Improvement
Is sold within one year of completion, the owner - bulkier erne d prov at he did
build Improve
OTHER (SPECIFY) ❑
not or for purpose of sale.).
❑I, as owner of the property, am exclusively cant ng wl d con actors o on&tr
the project (Sec. 7044, Business and Professions e: The C641raaor' ucenso- does
PROVIDE I.C.B.O. REPORT NQ.
apply to an owner of property who builder or improv thereon, and wM10 t a; for such prol
with pursuant to the Cc q mcbr'9llcenea Lew.
<7�
01 am exemptulten Se
❑Ism exempt antler Sec. 4 ,B8 P.C76U ler
9R4N9
PROVIDE MFGR. INSTALLATION SPECS.
Owner Data
WORKER'S COMPPPLICATION
ENSATION DEC- DEC
DATE
VALUATION
PERMIT FEE
I h reby affirm under penalty of perjury one of the following dada
have and will maintain a Certificate of Consent to sell - Insure for War dips soon,
�� 7
ea pro Idatl for by Section 3700 of the Labor Code, for the performance pl the wor Ich Ihls
permit is Issued.
Building
�0
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section 3700 of
the Labor Code,
3b�F , Qp
Seismic
for the performance of the work for which this permit Is Issued. My Workers
l
Compensation Insurance carrier and Policy number are:
Total Z r
Carrier rurI PolicyNoa &,q– rn&
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 ($100) or less.)
I certify that In the performance of the work far which this permit Is Issued, I shall not employ
All roofs shall be inspected prior to any rooting material being
any person In any manner so as to become subject to the Workers' Compensation Laws of Cali-
fornia.
62'"L$
installed. If a roof is installed without first obtaining an
Date I V Applicant +���– 1L
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become
subject to the Workers' Compensation provislons of.the Labor Code, you must forthwith comply
Applicant understands and will comply with all non point
with such provisions or this permit shell be deemed revoked.
I certify that I have read this application and state that the above information Is correct. I agree
Source regulations.
to comply with all city and county ordinances and state laws relating to building construction, and
All roof coverings to be class a or better.
hereby authorize representatives of this city to enter upon the above - mentioned property for In.
spection purposes.
(We) agree to save, Indemnify and keep harmless the City of Cupertino against liabilities,
judgments, coats and expenses which may In any way accrue against said City In con&aquence
g
SIGNATURE OF APPLICANT DATE
of he granting at 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