R-6612•
0
APPLICATION FORp_ 30 CITY OF CUPERTINO
REROOF PERMIT U INSPECTION DIVISION
(408)777-3228
V Vvri J
NAME
ADDRESS
NAME
LICENSE 2,9-701
NUMBER (1/d
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Set
7000) of Division 3 of the Bu mess and Professions Code, and my license Is In full force
effect. fin• /' /
License Class LIC. Number K
Date Contractor
OWNER -BUILDER DECLARATION
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
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Lew (Chapter 9 (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
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civlt penalty of not more than five hundred dollars ($500).1:
I] 1, as owner of the property, or my employees with wages as their sole compensation, will do
the work, and the structure Is not intended or offered for sale (Sec. 7044, Business and Proles -
alone Code: The Contractors License Lew does not apply to an owner of property who builds or
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 completion, the owner -builder will have the burden of proving that he did
not build or improve for purpose of sale.).
❑ I, as owner of the property, em exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not
apply to an owner of proparty, who builds or improves thereon, and who contracts for such projects
with a contractor(s) licensed pursuant to the Contractors License Law.
❑ I am exempt under Sec. _ B B P. C. for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
the Labor Code, r the performance of the work for which this permit Is Issued. My Worker's
Compen lion
Pfirancit carrier and �al cy number are:
Carrier Iicy No.
CERTIFICATEOF EXEMPTION ROMWORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the, permit is 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 person In any manner so as to become subject to the Workers' Compensation taws of Cali-
fornia.
Date Applicant
NOTICE TO APPLICANT: If, ager making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
with such provisions or this permit shall be deemed revoked.
I certify that I have read this application and state that the above Information Is correct) agree
to comply with all city and county ordinances and state laws relating to building construction, and
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, costs and expenses which may in any way accrue against said City In consequence
of the granting of this permit.
PRE -INSPECTION: I PLYWOOD:
INSP. DATE INSP.
TEAR OFF INSPECTION: BATTENS:
PERMIT
NUMBER R- 6612
PERMIT EXPIRATION
PERMIT EXPIRES IF WORK 15 NOT STARTED
WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
V/RESIDENTIAL COMMERCIAL OTHER
YES ❑ If yes —1 understand that a Class A
roof assembly is required.
NO IInitial_ _ I.C.B.O. #
NUMBER OF EXISTING COVERINGS
TO BE
W42
EXISTING
TO BE RETAINED d
BUILT-UP ROOF ❑
ASPHALT SHINGLES ❑
WOOD SHAKES
WOOD SHI g�ES /n1 ri-i--
1 6 1999
ASPHALT
WOOD SHAKES ❑
WOOD SHINGLES ❑
OTHER (SPECIFY) ❑
PROVIDE I.C.B.O. REPORT NO.
PROVIDE MFGR. INSTALLATION SPECS.
PERMIT FEE
Building
Seismic �•
Total
PERMIT AUTHORIZATION I DATE
1 0 ro_/l_F
All roofs shall be inspected prior to any roofing material being
installed. If a roof is installed without first obtaining an
inspection, I agree to remove all new materials for inspection.
Applicant understands and will comply with all non point
source regulations.
All f coverings to be cls 'eor better.
NAT OF -APPLICANT DATE
FINAL:
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY _