R 6111 PERMIT6111
APPLICATION FOR CITY OF CUPERTINO NUMBERR-
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
— WITHIN DAYS PERMIT ISSUANCE OR
100 DAVES FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
C6DRESIDENTIAL COMMERCIAL OTHER
OWN Rf ` 1�vt1HAZARDOUS FIRE AREA
~��S J , lO AYES ❑ It yes—I understand that a Class
NAME
roof assembly is required.
NO ' Initial I.C.B.O.N
ADDRESS W EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S 1
J��Zp1_ `,� ,� C,�N ,^ TO BE REMOVED�TO BE RETAINED
NAME 111"'��` i-�AiYY1 �
ADDRESS TYPE OF ROOF COVERING.
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOF ❑
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing wil ion WOOD SHAKES
7000)of Division 3 of the Business and Professions Cotle,and my license Is in full force
effect.
ODD SHINGLES ❑
License Claes Lic.Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am 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 re a the BUILT-UP ROOF ❑
applicant for such permit to file a Signed statement that he Is licensed pursuant to the ov alone
of the Coolmctor's License Law(Chapter 9lcommencing with Secllon 7000)of Divisi f the
Business and Professions Code)or that he Is exempt therefrom and tna basis for t god AS"ALT'S
NGLES EJ
exemption.Any violation of Section 7031.5 by any applicant for a permit subjecle the a c tto
a civil penalty of not more than five hundred dollars($500).): W OD SHA E$
❑I,as owner of the property,or my employees with wages as their sole compensat wind ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Busineaa a Profess EP 1 00
slons Code;The Contractor's License Law does not apply to an owner of property wh ullds or WOd SHI LES ❑
Improves thereon,and who does such work himself or through his own employees,pr atl that
such Improvements are not Intended or offered for Sale.If,however,the building or I rovement
Is sold within one year of completion,the owner-builder will have the burden of proving hBnoditl OTHER(SP CIFY) ❑
not b d or improve for purpose of sale.). _7
as owner of the property,am exclusively contracting with licensed contractors to construct
I
project(Sec.7044,Business and Professions Cade:The Contractor's License Lew does not PROVIDE L .B.O. REPORT NO.
a ply to an owns ropery who builds orimproves the on,and who contracts for such projects
withaco act (s is tlpunua me Contracto ucenee Law. 'PROVIDE MFGR.INSTALLATION SPECS.
`��//' ❑ e e do, e B 8 P.C.for this res on
// Own Date APPLICATION DATE VALUATION PERMIT FEE
W K 'S COMPENSATION DECLARATION
h eby affirm der penalty perjury one of the following declaration: l
Pheve end affil,/
melnlaln ertlllcete of Consent to self-insure for Worker's Compensation, / A 9 Building
/
permitprovided forIssued.
ssue Section 3700 of the Labor Code,forme performance of the work for which this Fir ` O� �
permit le le and Seismic
❑I have and will maintain Worker's Compensation the workfor Insurance,as required by Section 3700 s
the p Labor Code,for the performance of the ware for which this permit Is leauetl.My Workers
.the
Insurance carrier and Policy number are: Total/
Carrier PUIIcyNo. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N
(This section need not be completed If the permit Is for one hundred dollars($100)00)or lase.)
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any person In any manner so as to become subject to the WorkereCompensetlon Laws of Can- All roofs shall be inspected prior to any roofing material being
fornla. 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,after making this Certificate of Exemtion,you should become A Ilcant and lands and will cora
subject to the Workem'Compensetlon provlelons of the Labor Code,you must forthwith comply Applicant ply with all non point
with such provisions or this permit shaiffoe deemed revoked. sour (egul 10 S.
I certify that have read this application and erste that the above Information is,correct. agree
to comply with haall city and county ordinances and state laws relatingto nfrmatinncnstruction,end Allrof c0 n 0 class' rbetter.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,coats and expenses which may In any way accrue agalnst said City In consequence
of the granting of this permit. TURF OF PL T DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRE
INSP. DATE - INSP. DA 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