R 6048 (2) PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 6048
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
00 73 01-01, RESIDENTIAL COMMERCIAL OTHER
OWNER'S o HAZARDOUS FIRE AREA '
NAME (� YES [:] If yes—I understand that a Class A
roof assembly is required.
NO E] Initial I.C.B.O.N
ADDRES2=0 0 4. EXISTING ROOF COVERING
NUMBER OF EXISTING C VERINGS
PHONE 1
CONTRACTOR' 1
NAME BE REMOVED TO BE RETAINED
ACITY&21PDDRESS -2 /G 7 O ' t
EXISTING I TYPE OF ROOF COVERING
r-Z X STING
PHONE BUILT-UP ROOF ❑
LICENSE ❑
NUMBER ASPHALT SHINGLES
L CENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Beninese and Profession e,end m license ie In fu or and
effect.
WOOD SHINGLES ❑
License C as c.Number
Data contractor OTHER(SPECIFY) ❑
hereb ffirm that I em exem
pt from h the Contractor's DECLARATION
Law forme following reason. PROPOSED
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,after,improve,demolish,or repair any structure,finer 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 provisions
of the Contractor's License Law(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 Budged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant 10
a civil penalty of not more than five hundred dollars(E500).): WOOD SHAKES
El 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 Prof...
storm Code: The Contractors License Lew does not apply to an owner of property who bullus 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 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 OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑1,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 contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,a 6 P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLI ATION DATE VALUATION PERMIT FEE
Iehereby affirm under penalty of perjury one of thfollowing declaration:
❑
have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, T o Building as provided for by Section 371X)of the Labor Code,for the pedormance of the work for which this g
permit Is is Seismic
Z=antl will maintain Workers Compensation Insurance,as required by Section 3700's PAIR 3 7, p
the Labor Cotle,for iha edormenc f the work for which this permit is Issued.My Worker's
Compensation'uure nieran licy number are: / Total
carver.:1 x ' c 4 PolicyN2�—�01� PERMITAUTHORI 1 DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ Tq Q IZ [�
(Tele section need not r antecompleted
the
If the permit is for one hundred dellen shall($100)not
less.) lJ V( ���r VCIJV
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 werkere'compenaatlon Laws of call. All roofs shall be inspected prior to any roofing 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.
subjectOTICE to the Wokers'Compensatlon proviPLICANT: It.after sions oche Labor Exemption,
ode you must rodhwshould
iithbecome
comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. source regulations.
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 All i QS to a Ss"C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may in any way accrue against said City in consequence Si URE OF APPLICANT AT
01 the granting of this permit.
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