R 6019 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 6 019
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
Ali 180 DAYS FROM LAST CALLED INSPECTION.
UILDING ADDRESS
RESIDENTIAL# -COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ Ii yes–I Understand that a Class A
NAME roof assembly is required.
NO ❑ Inihal I.C.B.O.N
ADDRESS EXISTING ROOF COVERING
/
PHONE NUMBER OF EXISTING COVERINGS
CONTRACT
NAMTO BE REMOVED TO BE RETAINED
E ^�/Rr _ R• JD r
ADDRESS / TYPE OF ROOF COVERING
CITY&ZIP 3 _�
/�� EXISTING
G
PHONE / DJ 7,1407 BUILT-UP ROOF ❑
LICENSE r -
NUMBER 3 ASPHALT SHINGLES ❑'
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES 2"
7000)of Division 3 of the Business and Professions Cotle,and my license Is In lull force and
effect. C-34 WOOD SHINGLES �UG .�r0
License Class Lic.Number
OTHER(SPECIFY) nr`-'�1
.Date contract rr GIIY 11Y VDT"r..E-'mNI?.
OWNER-BUILD DECLARATION PROPOSED
I hereby a Irm that I am exempt from the Contractors License Law for the following reason.
(Sec.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 ❑
apolcanl for such permit to Ills a signed statement that he Is licensed pursuant to the provisions '1/iQ yitq
.
of the Contractor's License Law(Chapter B(commencing with Section 7000)of Division 3 of the ••
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ��/�/�
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to se
a civil penalty of not more than five hundred dollars($500).):
01.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 Profes•
alone Code:The Contractor's Licence Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.If.however,the building or Improvement
Is sold within one year of completion,the ownenbulidar will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of eels.).
❑I,as owner of the property,am exclusively 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 Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
]I am exempt under Sec. ,B S P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: . -
❑I have and will maintain a Certificate of Consent to solf-Insure for Worker's Compensation, Building
/y!
as provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this
permit is l /D ODD Seismic
-D—
❑Ihove have and antl will melnlaln Workers Compensallon Insurance,es required by Section 3700 0l
.the Labor Code,for the performance of the work for which this permit Is Issued,My Workers
Compensation Insurance carrier and Policy number are: Total
Carrier 'LNn Policy No/u�379PERMIT 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 less.) G
I cerilfy that In the performance of the work for which this per It is Issued.I shell not employ
any person In a m ner so as to became subject Wo r8'Compensation Law.of Can• All roofs al a Inspected prior to any roofing material being
fornix. installed. If a roof is installed without first obtaining an
Data
Appnp.nt - inspection,I agree to remove all new materials for inspection.
NOT E APPLICANT: If,.flex making Ihl e a of Examptlon,you should become Applicant understands and will comply with all non point
subtest o In Workere'Companaetlon pmvlel o e Labor Coda,you must forthwith compty PP p y p
with such provlalona or It permit she
revoked. Source re don
Icerfltylhef!have read this applicatlo n to that the above Information is correct.I agree
to comply with allclryentlmunry oral ce tleletetawe ralatingto bulltlingconevucdon,ens All roof OVer sto be class"C"or better.
hereby authorize representatives oft a c4it enter upon the above-mentioned imparty ror in-
spection purposes.
(Ws)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,coats and expenses which may In any way accrue against said City in consequence SI TU F APPLICANT AT
of the granting of this permit.
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