R-6253 PERMIT R-
APPLICATION FOR CITY OF CUPERTINO NUMBER 6253
REROOF PERMIT - INSPECTION DIVISION PERMIT EXPIRATION ,
(406)777-9226 ORK iS NOT STARTED
WITHIN 160 DAYS OF 9 EXPIRES IF PERMIT ISSUANCE OR
160 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
4-11
I
1c) k7 RESIDENTIAL—COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
y YES'❑ If yes—IrWerstand that a Class
NAME M(!-kt�Q. P(-c:J �,(�—� roof assemhly Is required. "
j� NO ❑ Initial I.C.B.O.7
ADDRESS- 3'5U lJ r((�' 4 '� Qe .16 k A EXISTING ROOF COVERING
PHONE O 'rte (p '� S -y—� NUMBER OF EXISTING COVERINGS f
CONTRACTOR'S
NAME T1'lAet�0 r ' Qv 4-f rk.n. (( i TO BE REMOVED� TO BE RETAINED
TYPE OF ROOF COVERING
ADDRITY ESS
PHONE >� r WILT- OOF ❑
LIIUMB ERCENSE �. I U 9 ,/A$P,.H SHINGLES
LICENSED CONTRACTORS DECLARATION IyJtS
I hereby affirm that I em Zrised under Provisions of Chapter B(comhKr'd41 In Seclfon WCO KES //�
7000)of DMsion 3 al Me Business and Profeeebns Corse,entl my license Is In ull force entl' /-y`11
effect. W
/� ��j WOODS INGLES ❑
Ucanse Class Uc.Number SZU'lV
Date Camaotor o-i OTHER(SPECIFY) A
OWNER-BUILDERDECLA ION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Business and Professions Cotler Any city or county which requires a pamdt to
construe(alter,Improve,demolish,or repair any structure,prior to lb issuance,also requires the BUILT-UP ROOF El
for such permit to file a signed statement that he Is licensed pursuant to the pro rabne
01 the Contractors Llamas Law(Chapter g(commendrq lh Seetbn 7000)of DlvUlon 3 of Me
Business and ProfesWons Code)or Mat he Is exempt therefrom and the Iasis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects Me applicant to
a civil penalty of not more than five hundred dollars
01,as owner of the property,or my employees with wages as Melt sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profa,-
Wons Code:The Contractors Ucense Low doe,rot apply to an ownn W property who siode or WOOD SHINGLES -
Improves thereon,and who does,such work himself«through his own employees,provided Mat ❑
such improvements are not Intended or offered for able.II,however,the building or Improvement
Is sold within ora year of completion,the owner-bullder will he"the burden of prWgthat he dlo OTHER(SPECIFY) El
build or Improve for purpose of sale.).
❑1,as,owner of Me property,em exclusively contactingg with licensed contractors to construct
the project(Sec.7041,Business end Professions Code:The Contactors Ucense Low time trot PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who Wide or Improves Maroon,and who contracts for auch projects
with a contruclor(s)licensed pursuant to the Contractor,ucense Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt unser Sec. a a P.C.for this reason
owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following decierabon:
❑I have and will maintain a Certificate of Consent to,eMlnsure for workers Compensation, Building/3 -7
as provaed for by Section 3700 of the Labor Coes,for Mar perlgrmance of the work for which the `
permit is Issued' (j(� Seismic
❑1 he"and will maintain Worke re Camp,neatbn Insu ranee,as required by Section 3700 of v�
the Labor Code,for the performance of the work for which this permit Is Issued.My Workers -gyp O,
Compensation Insurance�carrle-raMryIIcy number are: - / Total 1/17. 10
CemlerJ � 7=- / PolicyNP166y7 ` 7 PERM IT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ad.op /
(This section need rot be completed II Me Permit Is for one hundred dollare(5100)or less.) `
I certify that In the performance of Me work for which this penmlt Is issued l l shell not empIq'
17
any Person In any manner so as to become subject to Me Workers'Compansaton Lewy of CalF All roofs shall be inspected prior to any roofing material being
forma. D!/ installed. If a roof is Installed without first obtaining an
Date "f�L Applicant ,/'�r�+(� inspection,I agree to remove all new materials for inspection.
NOric TO APPLICANT: It,after makingfhls Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provalons of the Labor Code,you must forthwith cornpty pp P Y p
with such proyidons or this permit"qba deemed revoked. source regulations.
I"My that l he"read this application and state Met the above Information Is comect.I agree �
to comply Miff all city and county ordinances and sate laws relating to Wiping commuctlon,entl All roof coverings to be classk or better.
hereby authorize representatives of this city to enter upon the abave-mentbnetl property for In- I(
epectlon purposes. �Y Y�
(We)agree to save,Indemnlfy and keep harmless the City of Cupertino ahat Ilabllfirw _
ofdMe granting of the penMt�welch may In any way accrue against salol Gry�n consequence NATURE OF APP ANT DATE
PRE-INSPECTION: - PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. pS DATE ��r_O SP. DATE INSP. - DATE
NOTE: OSHA APPROVED ACCESS TO ROORSHALL BE PROVIDED FOR INSPECTION.
OFFICE COPY