R-6093 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R" 6093
INSPECTION DIVISION - PERMIT EXPIRAMOP .
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.
BUILDINGADDRESS C` AU ,
RESIDENTIAL_ZCOMMERCIAL OTHER.
owNER'S 7 ✓ �t '' HAZARDOUS FIRE AREA
1
NAME Zit ` 'W Ip�V YES ❑ a��y red C7assA
. roof- - NO, ❑ - ImfiI I.C.B.O.M
G
ADDRESS L IIA Z_ K_. 0(4 - EXISTING ROOF COVERING
PHONE Z SS— 3 3 0 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME - /
-P'o RW,F/".1G ,/C 4gCO C/HI C TO BE REMOVED ` TO BE RETAINED
ADDRESSTYPE OF ROOF COVERING
ADDRESSCITY&ZIP �D/x4 �s (f-eel' cDQ 5,01 c 2
C_./a q S v-6 2 - - EXISTING .
PHONE S O g — 3 7 - X99 BUILT-UP ROOF• ❑
LICENSE
NUMBER 61S ?j ASPHALT SHINGLES ElJ
LICENSED CONTRACTORS DECLARATION -
I hereby affirm that I em Ibereed under provblons of Chapter 9(commencing with Seclbn WOOD SHAKES
7000)of Dlvison 3 of the Business and Professions Code,and my license Is In full force and '
effect.
Q WOOD SHINGLES El.Dcenae Cess y �� Lk.Number ��p�^q'
Date Contractors 'OY) El
OWN � V1 OTHER(SPECIFY)
DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's License Law for the follaNng reeSon.
(Sac.7031.5,Business and Profeaebns Code: Any chy or county which requires a permit to
construct.alter,knoum,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is Ilcered pursuantaa
eto the P1011sls
of the ContmcYors License law(Chapter 9(commencing with Section 7000)of Division 3 0l the-
Business and Professions Code)or that he Is exempt therefrom and the basis for the allegedASPHALT SHINGLES ❑
bl
exemption.Any vatbn 03
of Section 71.5 by any applicant for a permit subjects the applicant to
a chrl penalty of not more than five hundred dome(5500).): !
❑1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES
the work,and the sh ctum Is not Intended or offered for sale(Sec.704/,Business and Probes- ,
slons Code:The Contractor's LJcenee Lew does not apply to an owner of property who LES
improves thereon,and who does such work hlmsell or through his own employees,pro,drol met
such Impraemants ere not Intended oroffered lar sale.If,however,the budding crimps ant
Yat build or Imprva for completion,theowner-Wilder will nave Meburden of prwbg tlld 78P
IFY) /
not build or Impwie ion purpose of aaleJ.
❑1,tie owner of the property,em exclusively contracting with licensed contractors toJG ,
Me project(Sec.70/4,Business and Professions Code:The Contractors Dceree Law note, .O.REPORT NO.
apply to an owner of property wnd Wide or lmpro ms thereon,entl wnd contracts for su
wW a conuaptor(s)licensed pursus i to me Contractors License Law. R, INSTALLATION SPECS.
❑I em exempt under Sec. ,B 8 P.C.for IN reason
Owner Date IRV
WORKER'S COMPENSATION DECLARATION E VALUATION PERMIT FEE
I hereby affirm umber penalty of pedury one of the following declaration: -
❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, Building
as provided for by Section 3700 of Me Labor Code,for the parformanco o the work for which the /
permit Is based.
I]I have and will maintain Worker's Compensation Insurance,as requlred by Section 3700 of elsmlc
the Labor Code,lox the performance of the work for whlctn the permit is esued.My worker's
' Compensation Insurance carrier and Policy number are: Total
' Cerner Policy No. PERMIT ALT RIZATION DATE.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need not be completed If the permit Is for once hundred dollars($100)or less.) 0
I certify that In the performance of be work for which this permit Is Issued.I shell not employ
any person In arty manner so as to become Subject to the workers Compel
nsation Law.of Cali- All roofs shall be inspected prior to any roofing material being
fomla. installed. If a roof Is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE a APPLY'Comps eater mesons of this the Latbor lCode,you you should become Applicant understands and will comply with all non point
subject to the Workers Com ,after
you must shout h comply
with such provisions or this parmh shat be deemed revoked. source regulations.
I teddy that I have reed this Implication end state Met the above Information Is correct.I agree
to comply with all city orrd county ordlrences and state laws relating to building construction,end- All roof Coverings to be cla or better.
hereby authorize representatives of this dty to enter upon the abme-mentioned property for In- '
specton purposes.
(We)agree to save,IndamMy and keep harmless the City d Cupertino egamna IlabWties
ju ments,costs and expenses which Trey In any way accrue against Bald city In consequence 111
on a granting of the permit. SIGNATURE OF APPLICANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: J BATTENS: - FINAL:
INSP. DATE�/ INSP. DATE INSP.-DATE
NOTE: OSHA.APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY - 7