R 6280CJ
10
•
OFFICE COPY
ERIT
NUMBER R- 628
APPLICATION FOR clTv of cuPERnrvo
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
" WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING AADDD/RESS -
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2 �/ C O
J✓ N / +(/
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
' l
/ 1 iY .—
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YES EJIf yes — I understand that a Class A
NAME _ (��
roof assembly is required.
NO ❑ Initial I.C.B.O. #
EXISTING ROOF COV RING
NUMBER OF EXISTING COVERINGS �//X? /��
ADDRESS
-7
Z 5— ga G/y
PHONE
TO BE REMOVED TO BE RETAINED
CONTRACTOR'Sy^-
NAME / / / V d✓�— G G
ADDRESS iJ 3 % _ G „ 1%✓/g(,
TYPE OF ROOF COVERING
CITY &ZIP y� (�
EXISTING
2 45 y /4105—
PHONE
❑
BUILT-UP ROOFLICENSE
3 -3
NUMBER S7 2 3 /
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8 (commencing with Section
WOOD SHAKES {s]--
7000) of Division 3 of the Business and Professions Code, and my license Is In lull force and
effect.
�� 3 5-2,33/
WOOD SHINGLES ❑
License Class Lie. Number
�lw��/ Gr9`
OTHER (SPECIFY) ❑
Del. contrector
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
PROPOSED
(See. 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 ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Lew (Chapter g (commencin with Section 7000) of Division 3 of the
Buslness Professions
f/
and Code) or that he Is exempt therefrom and the basis for the alleged
ASPHALT SHINGLES
exemption. Any violation .1 Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dOtlare ($500).):
❑1, as owner of the property, or my employees with wages as their Sole compensation, will do
WOOD SHAKES ❑
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Proles-
-
aions Code: The Contractor's License Law does not apply to an owner of property who builds or
Improves thereon, and who does such work himself or through his own employees, provided that
WOOD SHINGLES -❑
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.).
❑ I, as owner of the property, am exclusive 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 Contractor's License Law.
em exempt under Sec. ,B & P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.I
Owner Data
' WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ 1 have and will maintain a Certificate of Consent to sell -Insure for Workers Compensation,
BUlldln ��
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit Is Issuedhave
g
Seismic
and.
❑ have end will maintain Worker's Compensation Insurance, as required by d. my Workers 3700rs
the Labor Code, for the performance of the work for which this permit Is laeuetl. My Workers
Compensation Insurance terrier and Policy number are:
1 /y
�
� D� v
Total �Q
Carrier, Policy No.
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
- COMPENSATION INSURANCE N.C.[]
(This section need not be completed If the permit Is for one hundred dollars ($100) or lees.)
`
I certify that in the performance of the work for which this permit is Issued, I shall not employ
All roofs shall be inspected prior to any roofing material being
any person In y man r eo Said become eubJ ct to ins Workers Compone t1n Laws of call.
fernla' Q)
P
installed. If a roof is installed without first obtaining an
D.I. Applmanc
inspection, I agree to remove all new materials for inspection.
NOTIC TO AP LICANT: If, after making tole Certificate of Exemption, you should become
subject t the Workers' Compensation provisions of the labor Cotle, you must forthwith comply
Applicant understands and will tom
PP ply 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. I agree
to comply with all city and county ordinances and state laws relating to bulltling construction, and
All roof coverings to be class 16 or better.
hereby authorize representatives of this city to enter upon the above-mentioned property ler In.
,
spection purposes.
---
�p
(We) agree to save, Indemnity end keep harmless the City of Cupertino against Ilabllltlea,
jutlQmenta. costs and expenses which may In any way accrue against said City... conaequenca
of the granting of this permit.SIGNATURE
Gw
OF APPLICANT DATE
PRE -INSPECTION:
PLYWOOD:
IN -PROGRESS:
INSP.-DATE
INSP. t" 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