R 6055 APPLICATION FOR ; CITY of cuPERrINo
NUMBER R- 6055 ,
REROOF PERMIT INSPECTION DIVISION - PERMIT EXPIRATION,
(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 '
I Z V RESIDENTIAL COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA
NAME IT 1 ny YES ❑ It yes—I understand that a Gass A
roof assembly is required.
NO ❑ Initial I.C.B.O.q
ADDRESS �LS�V EXISTING ROOF COVERING
PHONE L '— I LI L NUMBER OF EXISTING COVERINGS
CONTRACTOR'S -
NAME Cr L 0-/V (, e N)G 1w TO BE REMOVED TO BE RETAINED
ADDRESS -!��R TYPE OF ROOF COVERING
CITY Bzip L4kiAVS gSooh
PHONE -1 7 7 �7 7 1 BUILT-UP
EXISTING P ROOF ❑
LICENSE Z ASPHALT SHINGLES ❑ �' ,�
NUMBER 9�
LICENSED CONTRACTORS DECLARATION
hereby ialll.nion that em licensed unser Professions
eon.of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 0l the Business and Proleaelone Code,and my license Is In lull furca and
effect. WOOD SHINGLES ❑
License Class Llc.Number _
Date Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law 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 BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pureuant to the Provisions
of the Contractor'°License Law(Chapter B(commencing with Sectlon 7000)of Division 3 of the
• Business and Professions Code)or that he is exempt therefrom and the basis for the allegedep .
exemption.Any violation of Section 7031.5 by any applicant for a permit subject.the applicant to
a civil penalty of not more than live hundred dollars($500).):❑I,es owner of the property,or my employees with wages as their Bole compensation,will do the work,end the structure le Lic Intended ores not fol°ale n ow er of Business antl Profs°- ❑impro Cotle:The Contractor°Licence Law tl i s not apply to en owner of property who ided t orimproves thereon,antl who tloended work himself or mrouoh hl°own employees,Improved matIs sold auch w1thin one ye aro not pleb n,th offered for leer.ill however,the en ofpr o i rap at hedi t
ntbuild ori prove r of forpurposetlogthe Owner-builderwill have theburtlenof provingthat he didnot build or Improve far purpose of°ale.),❑I,as owner of theproperty,am exclusively contracting with licensed contracture to constructO.
the project(Sec.7044,Business and Professions Code:The Contractor's Unon.a Lew does not
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
E]I am exempt under Sec. ,B B P.C.Mr this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
O
I hereby affirm under penally of perjury one of the following declaration; /67
�..x
E)I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, BUlldln 1/
as provided for by Sectlon 3700 of the Labor Code,for the performance of the work for which this [/ g
permit la Issued.
�a
❑I have end will meMteln Worker's Compensation Insurance,as required by Section 3700 01 S I 7 O Seismic/
the Labor Code,for the performance of the work for which this permit Is Issued.My Workers Total /6y) Z
Compensation Insurance carrier and Policy number are: o
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE .N.C.p -
(This section need not be completed If the permit Is for one hundred dollars($100)or leas.)
t In
any personInany mannerrrmance of the work for so a°to become subject to the Which thisorkers'Compensermit Is elllo�aLaws am lay All roofs shall be inspected prior to any roofing material being
forofa. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: II,alter making this Certificate of Exemption,you should become Applicant understands and will cpm
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply ply with all non point
with such provisions or this permit shalgbo doomed revoked. source regulations.
I certify that I have read this application and state that the above Information 1s correct.I agree
to comply with all city and county ordinance°and state laws relating to building construction,and All roof coverings to be class i7or better.
herebyauthorize representatives of this city to enter upon the above-mentioned property for In
hereby purposes, LJ1 Mit Ws'xiri� /
(We)agree to save,Indemnity and keep harmless Na City of Cupertino against Ilabllitlea,
Judgments,coats end expenses which may In any way accrue against said City In consequence
• of the granting of thea permit. SIGNATURE OF APPLICANTAte-TE
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