R 6097•
•
OFFICE COPY
NUMBER R— 6 9
APPLICATION FOR CITY OF CUPERTINO
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
'
RESIDENTIAL COMMERCIAL OTHER
OWNERS
HAZARDOUS FIRE AREA
I
B 0 01
VES �( N yes — I understand that a Class A
NAME Ob§�T • it Qd.1 C-_1 A -M S
/ - roof assembly is required. -
NO ❑ Initial I.C.B.O. N
/�
EXISTING ROOF COVERING
/
ADDRESS) srfa A fi
�— N
^
PHONE d � — 944/5- _
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
N /A
NAME I
TO BE REMOVED TO BE RETAINED
ADDRESSTYPE
A
OF ROOF COVERING
CITY & ZIP IJ
EXISTING
N /A
PHONE
BUILT-UP ROOF
LICENSE
NUMBER nJ A
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B (commencing with Section
WOOD SHAKES
7000) of Division 3 of the Business and Professions Code, and my license Is in full force and
effect.
WOOD SHINGLES ❑
License Class Llc. Number
OTHER (SPECIFY) ❑
Date
Conor
PROPOSED
OWNER -BUILDER DECLARATION
I hereby
affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec. 7031.5, s Code:
Professions Code: Any city or county which requires a permit to
alter, Improve, de
constapplicant
BUILT-UP ROOF ❑
ntthathepriortoifsissuance,alsoregrovanhe
pursue revisions
applicant for each permit to Ills oChapt statement that he Is licensedSection
License Law (Chapter B (commencing with Section i Div Stan o
of the Contractor'sProfessions
Business and Prolaselona Cotle) or that he Is exempt therefrom and the ba r the all ,�
Ag T SHINGLES '
exemption. Any violation of Section 7031.5 by any applicant for a permit Sabi Sppli
su
a civil penalty of not more than five hundred dollars ($500).):
Les owner of the property, or my employees with wages as their seism ation, will do
the
❑ �� /�
WO SHAKES <
rk, and the structure Is not intended or offered for sale (Sec. 7044, Bu i err����gqpp9-'i
cions Code: The contractors License Law does not apply toanownerof pro ty 83EPO
p�Q
19x'WiO
improves thereon, and who does such work himself or through his own emp1 s, that
SHINGLES ❑
provided
such Improvements are not Intended or offered for Sale. It, however, the bulldi or Improvement
is sold within one year of completion, the owner -Wilder will have the burden of roving that he did
OTHE (SPECIFY) .❑
not build or improve for purpose of sale.). B
❑ I, as owner of the property, am exclusively contracting with licensed cord
the project (Sec. 7044, Business and Professions Code: The Contractors License Law does not
E I.C.B.O. REPORT NO.
apply to an oponywh0 builds or improves thereon, and who contracts for Such projects
wit rector(s)I' need pursuant to the ontractors License Law.
I am exe oder Sac. ,B A P. C. for t '5 reason
PROVIDE MFGR. INSTALLATION SPECS.
ow Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby agir under penalty of perjury one of the following declaration:
have
❑ have and will maintain a Worker's
the cab of Consent to self -insure for Worker's Compensation,
r
guildin /
ea provided1 for by Section 3700 of the Labor Code, for the performance of
of work forwhich this
permit is Issued.
����'��
�O
g
SD—
❑ I have and will maintain Workers Compensation Insurance, by Section 3700
$81SRIIC
as required of
„the Labor Code, for the performance of the work for which this permit Is Issued. My Workers
„� 7 (r'n
Compensation insurance terrier and Policy number are:
Total
Carder . PokcyNo,
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
' COMPENSATION INSURANCE N.C.O
(This section need not be completed if the, permit is for one hundred dollars ($100) or leas.)
L n r q
I certify that In the performance of the work for which this permit is Issued, I shall not employ
All roofs shall be inspected prior to any roofing material being
any person In any manner so as to became subject to the Workers• Compensauon laws of Car.
fornia.
installed. If a roof is installed without first obtaining an
Data 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' Compensauon provisions of the Labor Code, you must forthwith comply
Applicant understands and will comply with all non point
with such provisions or this permit shalgbe deemed revoked,
I that I have that the
sours ulationS.
certify read this application and state above information is correct. i agree
to comply with all city and county ordinances and stela laws relating to building construction, and
hereby
hereby authorise representatives of this city to enter upon the above-mentioned property for in.
purposes.
All roof C rings to be class' " or better.
/ / 19�,
(We) agree to save. Intlamnify and keep harmless the City of Cupertino against Ilabiliffes,
G ay(
judgments, costs and expenses which may In any way accrue against Said City In consequence
of the granting of this permit
$ FIE 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