R 6101 PERMIT61 1
APPLICATION FOR CITY OF CUPERTINO . NUMBER R"
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT I (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
r WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
I C1
b /�i✓ RESIDENTIAL V COMMERCIAL OTHER
OWNER'Sc //� HAZARDOUS FIRE AREA
NAME ✓q,IV 1�/� f7r . ��o`J VES ❑ if yea—I istand req that a Class A
�/ riDOf 89aelBWy 19 reQalf9e.
NO ❑ - IrtNal LC.B.O.#
ADDRESS7 �i'r�/� / �✓7�f EXISTING ROOF COVERING
PHONE d ^ .2. : ^ J 7 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
r
NAME I' L 5�S ��! ��(O ems+' , TO BE REMOVED TO BE RETAINED
ADD RESS TYPE OF ROOF COVERING
CITY&ZIP
�f^ / q / EXISTING
PHONE �!d 1219 " ZQ LID "7�FJ`'� �z �i K� BUILT-UP ROOF ❑ "
LICENSEL-' 3 ii
NUMASPHALTSHINGLES ❑
BER J
LICENSED CONTRACTORS DECLARATION �-1
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES Er-
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
WOOD SHINGLES ❑
License Claes LIC.Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
1 hereby affirm Ines I am exempt from the e: Any
License Law for the following reason,. /
(Sec.7ct.alt ,Improve and Profedemolish,
or rep Code: Any city or county which re,also e permit to
construapplicant
for alter,Improve,to file a signed air statement
Is licenseor to Issuance,to the
stns BUILT-UP ROOF ❑
applicant for such permit a file a signed statement that g le licensed pursuant to the provisions p�
• of the Contractor's License Lew(Chapter 9(commencing with therefrom
and 7000)of Division 3 le the f
exemption.
and Professions Code)or that he Is exempt antfora and the beefs for the alleged ASPHALT SHINGLES ❑
exemption.Any f not ion of than
Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penally of not more then live hundred dollars($500).):
1,as owner of the property,or my employees with wages as their sole compena Ill do WOOD SHAKES ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business ntl Pro es-
sions Code:The Contractors License Law does not apply to an owner of property w Is
or ;ID
D I GLES ❑Improves thereon,antl who does such work hlmsall or through his own employees,p d the such improvements ere not Inlontletl or o#ered for sale.IL however,the bulltling or I men �u/�9la sola wllhin onsyear of complallon,me ownar.bulltlerwill have the burden of provin he die R CIFY) p .1/not build or Improve for purpose of sale.). (��M1�]Ias owner of the property,am exclusively contracting with licensed contractor consuutL P�1 ojecl(Sec.7044,Business and Professions Code:The Contractor's License tloes not l C.B.O.REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for hprojects
with a contractors)licensed pursuant to the Contractor's License Law. FGR.INSTALLATION SPECS.
I e xemp r Sec ,B&P.0. tl�feason
er Date APPLICATI ATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building` x
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /
permit leIssuedve , V / ��,v Seismic O
❑1 have end will the performance
rmancWorker's Compensation Insurance,as required Is u Sectiod.My
Worker's of
_the Labor Code,for the pedmmand of the work for which this permit Is Issued.My Worker's
Compensation Insurance carder end Policy number are: Total /3 7r 0
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 ,�� � �1
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) ��C / 2—
1 certify that in the performance of the work for which this permit is issued,I shall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Call. All roofs shall be inspected prior to any roofing material being
fornix. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
0 NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should became Applicant understands and will Comply p
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP ply with all non Dint
with such provisions or this permit shelf;be deemed revoked. source regulations.
I certify that I have read this application and slate that the above Information Is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof cove ' gs to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spectlon purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
. judgments,costs and expenses which may In any way accrue against said Cify In consequence
of the granting of this permit. BIGNATURE 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY