R 6215 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 62
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-9228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
. BUILDING ADDRESS
RESIDENTIAL COMMERCIAL - OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME 0./S. �LL,�,/ SES ❑ If yeas I assembly
is
that a Class A
-roof assembly is andrequiredthat
NO ❑ Initial _ IC.B.O.#
ADDRESS , — EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'
- TO BE REMOVED TO BE RETAINED
NAME
ADDRESS $tvia � TYPE OF ROOF COVERING
CITY,&ZIP SU Own-
EXISTING
PHOIse6 43 -G33 �3 BUILT-UP ROOF
CENBE
NUMBER Z Q O ASPHALT SHINGLES ❑
LICEN ED CONTRACTORS DECLARATION
I hereby allirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑
]000)of Division 3 of the Business and Professions Code,and my license Is In 1.11 force and
effect.-fir .�2 70 a WOOD SHINGLES ❑
License Class Lill.Number s
LO OTHER(SPECIFY) ❑
Date Contractor
OWNER-BUILDER DECLARATION PROPOSED j
hereby affirm Bu rhes am exempt from me e: Any
or roue Lew for the following reason. -
const 10315,Business and Profedemolish,
or rep Code: Any city or county which requires also e permit to
applicant,orSuch permit t odea signed staair tny ement
thate,prior lolls Issuance,also the BUILT-UP ROOF
applicant for such permit a Ills a signed em( chef it licensed pursuant to the provisions
of the Contractor's License Lew(Getter h(commencingIsexpwith Section 1000)of for the 3 le the ❑
• Business and Protaeelop ode)or that he la exempt therefrom and the je is for the applicant
ASPHALT SHINGLES
exemption.Any vloletlodo •7971,0 any applicant fora permit eublacle the epplicent to
a civil penalty of not m re then Ilve u ZWMM�
❑I,as owner ollhaJyro arty,pray employees wlihw Irsolecompensation,wllldo WOOD SHAKES ❑
the work,and the ecruJyyt}(f snot Intended or pHeree for sal e�.1044,Buatness and Profes-
sionsCode:The Conpsteers License Law do9a not apply to an orner of property who builds or WOOD SHINGLES ❑
Improves thereon,enJJJ1 iylhd,do4s such work himself of through hisown employees,provided that
such improvements efelnpl inlaniladdr gflared lor,sale.If,he pVOr.the building or Improvement
Is sold within one yeak of cQmpletion;theoixn&.Wldaruwi11 havbt a burden of proving that he did OTHER(SPECIFY) El
build or improve for purpose of sale.).
❑I,as owner of ihq`prbperry,ere exclu vely contreding, censed contractors to construct
the project lSec.]044,9usineer(ejtd Prof honaPjede:T 11hctor'e Ucanae Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner ofproperty,�build�ori pfoyes mere d who contracts for such projects
with a contractor(a)licensed pursu91w1WhB„Cnlrectora a Law.
❑I am exempt under Sec. �`� f ,B 8 P.C.for this reason PROVIDE MFGR.INSTALLATION SPECS.
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
1 hereby affirm under penalty of perjury one of the Iollowing declaration: �s
❑1 have and will maintain a Certificate of Consent to performance
for Workers Compensation, - / / e p- Building
as provided for by Section 3700 of the Labor Code,for the petormanca of the work sof which this
perm)yyy sisauetl. O Seismic
eve end wIII maintain Worker's Compensation the work
kfor Insurance,lie required it Is I by Section Worker's �7 S�
„the abor Code,for the tainor Worker's
of the work for which this permit le issued.My Worker's
Compensation Insure ce c vier antl Policy meember are: �.•� 9f�' Total
Carrier ic.(_r{/ �/.�••O� Policy No. `,—• y 'Z PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.[J `0_
(This section need not be completed it the permit Is for one hundred dollars(S/00)or less.) l/ n
I certify that in the performance of the work for which this permit Is Issued,I shall not employ
any person In enylnannerso as to become subject to tna wwD afa'camewa of call- All roofs shall be inspected prior to any roofing material being
fon-la. / j/ G installed. If a roof is installed without first obtaining an
Date /Y f Applicant inspection,I agree to remove all new materials for inspection.
� E after TO APPLICANT: 11, making
flExemption.(ate of you become
Workers'Compensation proviions of the Labor Code,you msfo forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shalD.be deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information Is correct.I agree
tocomply with all city and county ordinances and state laws relating to building construction,and All roof coverings!gAeclasS° Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection
(we) purposes. �l//4
(We)agree to cave,Indemnify and keep harmless the City of Cupertino against liabilities,
'in
luegmeme costa end expenses which may In any way accrue against sato City In conseguance
. of he gm
SIGNATURE OF PPLICANT ATE
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 '