R 6105 y �
ERMIT
APPLICATION FOR CITY OF CUPERTINO ' NUMBER R 6105
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 ADDRESS
RESIDENTIAL_b< COMMERCIAL OTHER
OWNER'S c� HAZARDOUS FIRE AREA
NAME C'S I L J 6 e..Y YES C] If yes-1 understand that a Class A
L L
roof assembly is required.
O NO ❑ Initial I.C.B.O.#
ADDRESS EXISTING ROOF COVERING
PHONE C L7 e rT r a J`O/y NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S /- r
NAME � a 1 GA n Q\ 1'M C TO BE REMOVED TO BE RETAINED -
ADDRESSTYPE OF ROOF COVERING
)
CITY A ZIP d �Y V1('(� ST
saw�C> 1 l',t 4 K C)s 3 EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE S A
NUMBER ❑
LICENSE CONTRACTORS DECLARATION D
I hereby affirm that I em licensed under provisions of Chapter g(commencing with Section D W ;NM
7000)of Division 3 of the Business and Professions Code,and my license le In lull force and
effect rte+_ F-5 S ❑Llcenee Class ` Llc.Number-�� �� C � tl+) OTHER SPECIFY
Date Conlrectar--�r/-��r-(Q�-�� 4^v`!� (SPECIFY) ❑
OWNER-BUILDER ' tRROP
I hereby affirm Bu Chet am exempt from me e: Any.city or county
Lew for the following permit
t.
(Sec.70315,Business and Profedemolish,
or rep Code: Any city or county which requires also a permlt to
Construcapplicnt,orSuImprove,to file signed stateny ment that
Prior loIts Issuance,also the BUILT-UP ROOF ❑
applicant for ouch permit a Ill$a signed statement that he it licensedSection
pursuant t0 the provisions;the
of the ssContractor's License Lew(Chapter a(commencing with om and 7000)of Division 3 of the
Business entl violation o Coda)or thet he is exempt therefrom for
entl the beats for the allege ASPHALT•SHINGLES ❑
exemption.Any violationof Section 70315byany s($50 ).forapermit subjects the applicant
e dull penalty of not more than five hundred dollars($500).):
E]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 Protes-
alone Code:The Contractor's License Lew does not apply to an owner of properly who builds orOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provitletl that ❑
such Improvements are not Intended or offered for sale.If,however,the bullding or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did ER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑1,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 dose not PROVIDE I.C.B.O.REPORT NO,
apply to an owner of property who bulbs or Improves thereon,and who contracts for such projects
with a am exempt
licensed rSe pursuant to the Contractor's License Lew. PROVIDE MFGR. INSTALLATION SPECS.
❑)em exempt untler Sec. ,B 8 P.C.for this reason
Owner Date
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 self-Insure for Worker's Compensation, Bulldln27
as Provided for by Section 3700 of the Labor Code,for the performance of the work for which this g
permit Is Issued. p0 s G'T
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 o1 /`''� - f 3 $elSm' •..� V
-the Labor Code,for the performance of the work for which this permit is issued.My Worker's / -Y 7 s0
Compensation Insurance carrier and Policy number are: Total
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION the ON INSURANCE 100)o �S (� ^
(This section need not b. completed Nthe permit Is for one hundred dollars($100)or IesaJ �fxL 7 Jy
I 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 Workars'Compensation Laws of Can. 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 TO APPLICANT: If,after making this Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shalcbe deemed revoked. Source regulations.
I certify that I have read this application and elate 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 coverings to be class`47or better.
hereby authorize representatives of this city to enter upon the above-mentionad property for In. -
'spectlon purposes. ^ �]
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against old City In consequence DATE
of the granting of this permit. SIGNATURE OF APPLICANT
PRE-INSPECTIOM, 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