R 6408 (2) PERMIT R_ 6408
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WI1W DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS •r� `/ �//�/
Io3 5 M�U►� JRI v cRESIDENTIAL! ` COMMERCIAL OTHER
OWNER'SHAZARDOUS FIRE AREA
IkA— j1 `.I 1 �C YES ❑ If yes-I understand that a Class A
NAME Z M J roof assembly is required.
A I 1�, /J NO Initial I.C.B.O.#
ADDRESS q09—
�1.0�(3 g 5 I" A-Wifl -1 R• l.�lp�)�6 EXISTING ROOF COVERING
PHONE lu V 6 NUMBER OF EXISTING COVERINGS `
CONTRACTOR'S 7,00(,11-1!
p�,�/ ///
At
NAME T I'()0r')N Vj TO BE REMOVED TO BE RETAINED
DRESS lOd O�v, ._ n� -p� ;I 1 ..S _ Sb�Z TYPE OF ROOF COVERING
CITU&ZIP ll 0 GNB-`SN rf [ qp/ �U la E I N /
PHONE— ,469— 125 — ` `7 BUILT-UP ROOFLICENSE ❑ �j/
NUMBER Z S�9 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter S(commencing with Section WOOD SHAKES
7000)of Divle[on 3 of the Business and Professions Code,and my license is In full force and
°dOCL WOOD SHINGLES ❑
License Class v+ iNumber
Date-IIof) Contractor �VO�t"f OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that 1 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,eller,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to fila 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).): WOOD SHAKES ❑
I,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(Sea 7044,Business and Profes-
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not intended or offered far sale.If,however,the building or Improvement
is sold within one year of completion,the owner-bultdar will have the burden of proving that he did OTHER (SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions 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 contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. .B&P.C.for this reason
Owner Dale APPLICATION DATE VALUATION PERMIT FEE
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 Workers Compensation, Building
as provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this 1y I
perm) Is issued. (I I I Seismic
have and will maintain Worker's Compensation Insurance,as required by Section 3700 of l 1
t .L or Code,for the performance of the work for which this permit Is issued.My Worker's 1 Total
Compensation Insurance carrier and Policy number are:
Csrrier�Y-041't' l Policy NoW2-VOW ) 2 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If the permit is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit Is issued,I shell net employ
any person in any manner so as to become subject to the Workers'Compensation Laws of Cali- All roofs shall be inspected prior to any rooting material being
fornia. 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: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Componsatlon provisions of the Labor Code,you must brthwllh comply
with such provisions or this permit shall be deemed revoker. source regulations.
I certify that l have read this application and state that the above Information lscor agre All root coverin Class"(13r better.
to comply with all city and county ordinances and state laws relating to building co ruction,antl
hereby authorize representatives of this city to enter upon the above-mentioned roperty for In.
spectlon purposes. 2-' ZVd J
(We)agree to save,Indemnify and keep harmless the City a of Cupertino id Ci age t Ilablllilea,
of the gran costs and expenses which may In any way accrue against sale City In co uance (GNAT OF APPLICANT DATE
el the granting of this Dermic.
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
- OFFICE COPY - '