R 6129 (2) PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 612 9
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
YES ❑ If yes—I understand that a Class A "
NAME roof assembly is required.
NO ❑ Initial I.C.B.O.e
ADDRESS_. EXISTING EXISTING ROOF COVERING
L: -
PHONE O / �S.5 '� S '1Z.S NUMBER OF EXISTING COVERINGS
CONTRACTOR' I
19 TO BE REMOVED , TO BE RETAINED 1
NAME
ADDRESSefF� TYPE OF ROOF COVERING
CITY 8 ZIP 11:24 is 0�
gy553EXISTING
PHONLJq`15> to 99 - Y SS 48 BUILT-UP ROOF
LICENSE
NUMBER 4?46,
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter g(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect. `n' q WOOD SHINGLES ❑ !��
License Cleee `'- Lie.Number �`-
� OTHER(SPECIFY) ❑
Date _ _ Contractor
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors 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 pursuant to the provision -
of the Contractors License Law(Chapter S(commendng with Section 7000)of Division 3 of the
' Business and Professions Code)or that he Is exempt iherelrom and the basis for the alleged ASPHALT SHINGLES Cl
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($500).1:
01,as owner of the property.or my employees with Wages as their sale compensation.will do WOOD SHAKES ❑
the work,and the structure is not intended or allered for sale(Sec.7044,Business and Proles- f Oavv,-
alone Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑ rip„
Improves thereon,and who does such work himself or through his own employees,provided that such Improvements are not Intended or offered for Bale.II,however,the building or Improvement f $
-
Is sold within one year of completion,the owner-builder will have the bu rden of proving that he did OTHER(SPECIFY) kLJ
not build or Improve for purpose of Sale.).
O I,as owner of the property,am exclusively contracting with licensed contractors to construct -
the project(Sec.7044,Business and Profession Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
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 MFG R.INSTALLATION SPECS.'
O 1 am exempt under Sec. ,B 8 P.C.for this reason
Owner - Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
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, BuildinZ.g
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this QD g
permit is us ��98' / 30 �y Seismic
I have end will malman Worker's Compensation Insurance,as required by Section 3700 of (7 / ��
I abor Code,for the performance of the work for which thin permit Is Issued,My Workers
�Compensatian Inau cc carrl`a�r end Poli9yycJ((number ere: Total /
Carrier Policy No.S7/-97—g oo 4) PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O /� A
(This section need not be completed if the permit Is for one hundred dollars($100) e ) D t0 _ 2—
any
1
I certify that in the performance of the work for which this permit Is Issued,I shell toy 2— 1000
any person in an manner o as to become subject to th 'Compenaetlan all- II roofs shall be inspected prior to any roofing material being
lornla. I ailed. If a roof is installed without first obtaining an
Date Applicant I insp/ntion,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,alter making this Cartific of Exampflon shaved bee A pllEan nderstands and will cora
subject to the Workers'Compensation provisions of the Labor Code,you thwith comply,Q P Y ply with all non point
- with such provisions or this permit shalf♦be deemed revoked. I` sou Ce r tlonS.
I certify that I have read this application and state that the above Information lect.1 agree p�
to comply with all city and county ordinances and state laws relating to bulltling cone on,antl KWt/;00 rings Claes" rbetter.
hereby authorize representatives of this city to enter upon the above-mentionetl props r In- �O'
spectlon purposes,
(We)agree to save.Indemnify and keep harmless the City of Cupertino against Ilabillti -
judgments,costa and expenses which may In any way accrue against said City In consequence
of the granting of this permit, SI TLIFE OF PUCANT DATE
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