R-6456 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION p RMIT EXPIRAnoN
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
—1 _ RESIDENTIAL'V_1� COMMERCIAL OTHER
OWNER'S CC�� HAZARDOUS FIRE AREA
NAME `l k•C� YES ❑ r yes s understand is req tiled a Clens A
C�'/roof —I un Is required.
I- NO Initial I.C.B.O.A
ADDRESS � 7 -�' pK�C�C_J EXISTING ROOF COVERING
PHONE p NUMBER OF EXISTING COVERINGS
CONTRACTOR'S ,
TO BE REMOVED I TO BE RETAINED
NAME
ADDRESSL-� TYPE OF ROOF COVERING
CITY&ZIP J aL.1 -f'
EXISTING
PHONE �d� — ���fyl�5��9�3 BUILT-UP ROOF ❑
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKE
7000)of Division 3 of the Business and Professlom Code,and my license Is In full force and O
effect. CC
--c WO INGL$ ElLicense Clew cp-. a-9 Lb.Number '>
1 J ��, �p��y� b � \�\HE (SPECI�FYaO�Oj
Date � J Contractor /� �
OWNER-BUILDER DECLARATION P
hereby affirm that am exempt from the Contractor's orUlcerate,coup Lew for the uirowing permit
treason.
(Sec.7031.5,Business errd demolish,
or rooir Code: Any dry or county which requires a parmlt to r•
applicnstrant
Lor suImprove,demolish, ndstaemenny trthate,prlortoed!Its pursuantsnuarica,tothealso eprovisthe \�f ILT-UP ROOF ❑
of the oforstat perrntlto ills asignedr 9(coemthathe Iso ectio pursuant to the pro of
.7 �.1p
of the Contractor's UcemaoProfessions
Law(Chapter 0(commencingg with Section 7000)of for fie 3 0l Ne
Business end viclatelons Code)or Net he le exempt therefrom end the baste for Ne alleged A ti N LES ❑
a prof en.Anof not ore Section 7031 huric byany a($54Dnil«epermit subjects the applicant to vl
e tivil penally of not more than five hurMred tldlero(5500).):
❑I,as owner of the Properly,or my employees with wages as their sole compensation,will W DSHAKES ❑
the work,and fhe structure Ia not intended or offered!lar sale(Sac.7044,Buldness and Proles
ti Code:The Contractors Uconse Law does not apply to an owner of property who Wllds or WOOD SHINGLES ❑ I`fl .fes
Improves thereon,and who does such work himself or through his own employees,provided that �K
such Improvements are rot Intended or offered for sale.If,however,the Wilding or Improvement
Ie sold within one year of completion,the owrorWllder will have the burden of braving that he di (SPECIFY)
�y
rot Wild or Improve for purpose of sale.). ( I CI
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the protect(Sao.7044,Business srW Protonlons Corte:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who Wilds or Improves thereon,entl who conlracls for such projects
with a contraaoge)licensed pursuant to the Contractors Ucense Law. PROVIDE M FG R.INSTALLATION SPECS.
❑1 am exempt under Sac. ,B d P.C.for this reason
owner oats
WORKER'S COMPENSATION DECUBATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury orre of the following declaration: 7r
❑I have coal will melntain a Certificate of Consent to sell-Insure for Workers Com nsatbn, Buildin
ae provided for try Section 3700 of the Labor Code,for the perforrnenca of the work for which Nis / ��
permit Is Issued. `+ /
li; I ive and will maintain Workers Compenaallon Insurance,as required by section 3700 of Seismic
the Labor Corte,for the performance of the work for whkh this permit 15 Issued.My Workers / x
Compenanatbn Ineurence corder arW Policy number are: Tota/
Carrier \ ��-' °i `/x-t&h1=1 A Policy No.02Agpi"✓< -1— PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION theP INSURANCE NZ.100)o
(This eecdon need not be completed If the perm0 tri for one huntlretl dollen($100)or lase.)
I cedlfy that In the conformance of the w«k for which this Permit U Issued I shell not employ
any person In any manner ad as to became subject to the workers'ComPensetion Laws of can- All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date AppE:ent 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 cum point
subject to the Workers'Compensation provision of the labor Coce,you must forthwith rompty PP ply with all non Int
with such provisions or this Permit shall be deemed revalued. source regulations.
I codify that 1 he"read this application and slate that iha shwa Information is correct.I agree
to comply with all cry and county ordinances ano state laws relating to building construction,and All ro foven? IQ 'bB class or better.
hereby solhorlse representatives of this city to enter upon the abo+a.mentlonetl property for in.
ep(We)agrpoeas. / ^—
(We)agree to save,expenses
wend keep harmless the Gry of Cupertino against liabilities
of Me gnats,coats and expanses which may In any way accrue against Bald Gry In cortsequeroe
of Ne granting of Mb permit. G ATURE OF APPLICANT DAT
' 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