R 6001 (2) PERMIT R_
APPLICATION FOR CITY OF CUPERTINO , NUMBER 600,
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408)777-3228 WITHIN 180PPSTARTED
DAYS O PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWN 'S HAZARDOUS FIRE AREA
TYES ❑ If yes—1 uMerstand that a Class A
NA �I�+11.���[-Q'�S roof 1-01 dy Is required.
f NO Initial I.C.B.O.#
ADD 1 1 0 9 3 LV I KeNsI,LAI V 0.0 EXISTING ROOF COVERING
PHONE 7_74-0 NUMBER OF EXISTING COVERINGS 1 - 561ke-
CONTRACTOR'S k� r
TO BE REMOVED I TO BE RETAINED
NAME
TYPE OF ROOF COVERING
CITY&ZlP 14o1S &6kjhAc,,j �_A. Lot,Galbt� M3-�
S
EXISTING
PHONE !JQG-S5f-4028 BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby ethrm that I am 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
License
�� ❑
License Class � Lie.Number 7 30 ' WOOD SHINGLES
b-4-98
Date Contractor .QgA� OTHER(SPECIFY) ❑
OWNER-BUILDER DECLAR ION PROPOSED
I hereby affirm that I em 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 - El
for such permit to file a signed statement that he is licensed pursuant to me provislons �El
• of the Contractor's license Law(Chapter a(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 subject.the applicant to
a civil penalty of not more than five hundred dollars(5500)J: UN❑
C]1.as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES sss
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Proles. - I'v U
sions Code:The Contractor's License Lew does not apply to an Owner of property who bullas or WOOD SHINGLES CITY Improves thereon,and who does such work himself or through his own employees,provided that UtLq-
such Improvements are not Intended or offered for sale.If,however,the building or Improvement ctrl I Au
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) El
build or Improve for purpose of sale.).
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew 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 Lew. PROVIDE MF.GR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATIONAPPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: G7
❑I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, �— 1 gX C 1.��1 BGildin�0
as provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this FC// V J I- 1 W
permit Ia Issued.vandSeismic �
❑ have entl will the performance
Worker's Compensation Insurance,as required u d,My
Workers of
.the Labor Code,for the performance of the work r a which this permit ie issued.My Workers `
Compensation Insurance terrier and Poticy number are: Total
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OFFROM WORKERS'
COMPENSATIONATION INSURANCE RANCE N.
(This section need not be completed If the permit In for one hundred dollars(S )or less.)
I certify that In the performance of the work for which this permit Is Issued, aha not employ
any person In any manner so as to become subject to the Workers'compenaabon Laws of can- All roofs shall be inspected prior to any roofing material being
fornix. installed. If a roof is installed without first obtaining an
Date 6 Ti App=
�,Q• i�Q•t�. inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,eller meklnp thisertllicate of Exemption,you should become Applicant understands and will tom p
I with all non point
subject to the Workers'
ions or Compensation qbaprovisions em d the Leber Code,you must forthwith comply PP comply
with such provisions or this permit shalCbe deemed revoketl, sOUlCe fegUlafIODS.
I certify that l have read this application and elate that the above Information is correctl agree
to comply with all city and county eminences and state laws relating to building construction,and All roof coverings to be class" 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 Clry of Cupertino agairier liabilities,
judgments,costs and expenses which may in any way accrue against said City In consequence
'• of the granting of this permit. SIGNATURE OF APPLICANT 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