R 6323•
11
OFFICE COPY
PERMIT R_
6 3 C3,
APPLICATION FOR CITY OF CUPERTINO NUMBER
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
DV{v_o
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
YES [:]If yes — I understand that a Class A
NAME P•—��1
roof assembly is required. -
NO ❑ Initial I.C.B.O. q
-
Mo tl i4e Io4.Q,i1t CJ
EXISTING ROOF COVERING
ADDRESS -So , nAK.-o
NUMBER OF EXISTING COVERINGS /
TO BE REMOVED TO BE RETAINED
PHONE �O ��� — ��Ip Z,
CONTRACTOR'S
T3C.1 T e'O V �P'O S Q^�R 1
NAME �.�rt t'�
ADDRESS' -�1
TYPE OF ROOF COVERING
CITY & zip
EXISTING
PHONE X41 •"-03O7
BUILT-UP ROOF /////J ❑
LICENSE -
NUMBER
ASPHALT SHINGLES ❑
'
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I em licensedunder provisions of Chapter a (commencingwith Section
with
WOOD SHAKES
7000) of Division 3 of the Business and Professions Code, and my license Is In force and
effect.
WOOD SHINGLES
License Claes Llc. Number
Date Contractor
OTHER (SPECIFY) ❑
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
PROPOSED
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct, after, Improve, demollsh, or repair any structure, prior to its Issuance, also requires the
for
BUILT-UP ROOF ❑
applicant 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
a civil penalty of not more than five hundred dollars ($500).):
01, as owner of the property, or my employees with wages as their sole compensation, will do
WOOD SHAKES
the work, and the structure Is not intended or offered for sale (Sec. 7044, Business and Profes-
sions Code; The Contractor's License Law 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
WOOD SHINGLES ❑
such improvements are not Intended or offered for sale. If, however, the building or improvement
-
issoldwithinoneyearofcompletion,the owner -builder will have the burden of proving that he the
build or Improve for purpose of sale.).
OTHER (SPECIFY) Elno
as owner of the property, am exclusively contracting with licensed contractors le con
the r' act (Sec. 70", Business and Professions Code: The Contractors Liconse Law d
apply to an owner of property who builds or improves thereon, and who contracts for such
Q ROVE I. . REPORT NO.
p
with a contractor(s) licensed pursuant to the Contractors License Law.
❑ I em exempt under Sec. ,B $ P. C. for this ra
OP
PROVIDE M .INSTALLATION SPECS.
Own Date D
WORKER'S COMPENSATION DECLARATION
APP I T
N
VALUATION
PERMIT FEE
I hereby affir der penally of perjury one of the following declaration:
(:j 1 have and will maintain a Certificate of Consent to self -insure for Workers Compens lop,
Building/27,
as provided for by Section 3700 of the Labor Code, for the performance of the work for whit tNeY
Is Issued.
permit
❑ 1 have and will maintain Worker
Worker's Compensation Insurance, as required by Section 3700 of
$ eISmIC �
�---
the Labor Code, for the performance of the work for which this permit Is Issued. My Workers
Compensation Insurance
/ 2
carrier and Policy number are:
Total
Carrier Policy No.
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
�� 9
(^J
% / A/
COMPENSATION INSURANCE N.C.❑
. (This section need not be completed if the permit Is for one hundred dollars ($100) or Is".)
I certify that in the performance of the work for which this permit is Issued, I shall not employ
tv
r
All roofs shall be inspected prior to any roofing material being
any person In any manner so as to become subject to the Workers' Compensation Laws of Cali-
fornia.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
NOTICEecome
subject to he WoTO rkens'Compe�satio provmakinisions of theffLaborr ofode, you must forthwith comply mply
Applicant understands and will comply with all non point
with such provisions or this permit shalCbe deemed revoked.
Source regulations.
I certify that I have read this application and state that the above Information Is correct. I agree
to comply with all city and county ordinances and state laws relating to building construction, and
All roof coverings to be class" *gr better.
hereby
hereby authorize representatives of this airy to enter upon the above-mentioned property for Ira
purposes.
(We) agree to save, indemnity and keep harmless the City of Cupertino against liabilities,
judgments, costa and expenses which may In any way accrue against said City In consequence
of the granting of this permit.
SGNA3W4FE OF APPLICANT DATE
PRE -INSPECTION:
PLYWOOD:
IN -PROGRESS:
INSP. DATE
INSP. DATE
INSP. DATE
TEAR OFF INSPECTION:
BATTENS:
FINAL:
INSP. DATE
INSP. DATE
INSC,. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY