R 6168 (2) APPLICATION FOR CITY OF CUPERTINO NUMBER R" 6168
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
LLQ / C RESIDENTIAL COMMERCIAL OTHER
OWNEIR'S U HAZARDOUS FIRE AREA
YES ❑ If rooyes-I understand that a Class A
E
NAMf assembly is required.
NO ❑ InNal I.C.B.O.k
ADDRESS S lLVV-1, EXISTING ROOF COVERING
PHONE p NUMBER OF EXISTING COVERINGS /
CONTRACT S J,�
NAME -S 4� t_l ' TO BE REMOVED / TO BE RETAINED
ADDRESS )D0r �dx ) 9 3 TYPE OF ROOF COVERING
clry a zIP / (/�� � EXISTING
PHONE 4:5:7g— leg 33 BUILT-UP ROOF ❑
LICENSE fill❑
NUMBER "� �{- ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION S�
I hereby affirm that I am licensed under provisions of Chapter s(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is In full force and
effect. WOOD SHINGLES ❑
License Class y Llc.Number
Date contractor / OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION P D
I hereby affirm that I am exempt from the Contractor's License
(Sec.7031.5,Business and Professions Code: Any city or cou hlch requ'qq@@ permll
construct,alter,Improve,demolish,or repair any structure,prior to uence Iloi ulrea ih BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he is licon rsua 1 e vlslon
of the Contractor's License Law(Chapter 9(commencing with Se n 000)of Division 3 0l the
• Business and Professions Code)or that he Is exempt therefrom he jpr ipp elle ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a p 8 type Iloenn98
a civil penalty of not more than five hundred dollars($500).):
theCwork,and the structurepis not Intended employees
offered forsale(Se Od4 Buelneee ens Profas� WOOD SHAKES ❑
alone Coda:The Contrectoes License Law does not apply to anon of property who builds or WOOD SHINGLES ❑
Improves thereon,and who tloee such work himself or through his Io ass rovl aL-c�
such Improvements are not Intended suc or o work
himself
sal°.IL howeve
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY)
not build or Improve ler purpose of eels.).
❑1,asowner of the property,aman Professions
Code:
with licensed contractors to construct
the project(Sec.7044,Business who
pr ofessions Cotle:The and who
for sLawuch
does not PROVIDE LC.B.O.REPORT NO.
apply to c contractor(s)
properly who pursuant
or Improves thereon,and who contracts/or such projects
with a c m exempt ulcen Se pursuant to the Contractor's License Lew, PROVIDE MFGR. INSTALLATION SPECS.
❑I am exempt under Sec. ,B 8 P.C.for this reason
Owner oats
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penally of perjury one of the following declaration: _1 7
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building as provided for by Section 3700 of the Labor Code,for the performance of the work for which this g
permit is issued. Seismic 3 fl
❑ have and will maithe performance
Worker's Compensation the wokfor Insurance,as required Is i by Section 3700 of -�-r-�
the Labor Code,for the pedormence of the work for which this permit is issued.My Worker's / �Q 0 ,I.Otal D
Compene nInsurance.carr/[err a(n'depllicy umb/o/N'are: /^
Canler �r�S.�yC[7-/� 9policy No,
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE N.C.E
(This section need not be completed If the permit is for one hundred dollars($100)or leas.)
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 Workers'Compensation Laws of can- All roofs shall be inspected prior to any roofing material being
f°`nla. installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will Comply with all non point
subject to the Workers'Compansation provisions of the Labor Code,you must forthwith comply pp p y p
with such provisions or this permit Shell be 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 C Ings to be class"C"or better.
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, � � �0��9�
judgments,costs and expenses which may In any way accrue against said City in consequence
of the granting of this permit. SI A RE OF LI A 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