R 6214 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 6214 .
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (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 / COMMERCIAL OTHER
OWNER's, HAZARDOUS FIRE AREA
LYES E] If yes—I understand that a Class A
NAME NO roof assembly is required.
❑ Initial I.C.B.O.u
ADDRESS—'
DDRESS EXISTING ROOF COVERING
PHONE. NUMBER OF EXISTING COVERINGS /
CONTRACT
TO BE REMOVED TO BE RETAINED 1
NAME
ADDRESS , /SO G' / TYPE OF ROOF COVERING
CITV&ZIP— c.JlGti✓+
EXISTING
PHO N�(� `3 —63 BUILT-UP ROOF
LICENSE
NUMBER 8'Z /YXJ ASPHALTSHINGLES ❑.
LICENSED CONTRACTORS DECLARATION ,
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is in full force and
enact. q WOOD SHINGLES
License Claes Lie.Number O
Date � contractor - OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm Business
am exempt from the Comraclots License Law for the following reason.
(Sec.7031.5,BImprove entl Profedemolish,
0 yre p'Cetle`tructu a or county which ce,also e permit to
construct,alter,improve,to file asi oyrd Sta any ntithat e]slorAo es Issuance,also requires the BUILT-UP ROOF
applicant for such permit a flaw a slBnetl statement nci g with
S ctor In,to the provisions
of the ConiractoYe License Law(CI)4pt?8(commencing wllh Section 0)of Division 3 of the
Business and Professions Code)m.that he Is exempt therefrom and th hgsid for the alleged ASPHALT SHINGLES ❑
• exemption.Any violation of Secaon7031.5Wj anyappllcant for a permit subject the appllcant to
a civil penalty of not more than fiv¢IHuddre �d1 aW ftS�oo).): I'll
❑I,asownar of the property,grtiryemployees wltL agose thpksote compensation,will do WOOD SHAKES ❑
the work,and the structure is not intended or offered for salol( 0C.7044 9ypiness and Profes.
steno Code:The Contractor's Lipehs Lew rlpep nota ply to an ownerot prpparty who builds or WOOD SHINGLES ❑
Improves thereon,antl who tloes�eu2�work l self or Gough IS
own yeas,providod that
such Improvements are not Inlendedocp(fa ad for sale. f;h0& ar,ih Poing or Improvement
Is sold within one year of completion,the owderbWl er nfiavemebII pi proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.). aad`J�'
❑I,as owner of the property,am exclusively contracting wllh tic ntractors 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(()licensed pursuant to the Contractor's License Law, PROVIDE MFGR. INSTALLATION SPECS.
01 am exempt under Sec. ,B&P.C.for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
'
I hereby affirm under penalty of pedury one of the following declaration: , .�
I have and will maintain a Certificate of Consent to selbinsure for Worker's Compeneatlon, �! Building 10/
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 0��
perm have Oct. i` 300 / Seismic
have antl will maintain Workafs Compensation Insurance,es required by Secllon 3700 of
ih Labor Cotlo,for the performance of the work for which this permit Is Issued.My Worker's
Compensation.Ins�ura–nc,.e�rrler and Policy number are: Total O
Carrier _7_4_n�L Policy No. �I ZS PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 /
(This section need not be Completed if the permit Is for one hundred dollars($100)or lose.)
1 certify,that In the performance of the work for which this permit Is issued,I sine(not employ
any person In any nor so as to become subject to the Workers'Compensari Laws of call. All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date �� apv(eam inspection,I agree to remove all new materials for inspection,
NOTICE TO APPLICANT: If,after making tela Certiflcar 1 Exemption,you should become Applicant understands and will cora
subject to the Workers'Compeneatlon provisions of the L or Code,you moat forthwith comply PP ply with all non point
with such provisions or this permit shall he d9emed revoked. source regulations.
I certify that I have read this application and state that the above Information Is correct.I agree
tocomplywithall city and county eminences his ces entl sterelaws hela(ngtoent1ngdproery for
All roof cover or better.
hereby comply
with ze city and county
01 then City 10 d state
upon the above buildinn construction,property for and
�over
In-
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against Iabllidee' /ys�f
judgments,tesla and expanses which may In any way accrue against Said Ciry In consequence
of the granting of this permit. SIGNATURE APPLICANT U AI C
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