R 6003 APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 6003
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
S0 RESIDENTIAL COMMERCIAL (./ OTHER
OWNER'S HAZARDOUS FIRE AREA
�( ��/1 YES ❑ If yes s I understand that, Class A
NAME �U � e/l.L-ln l /it.r..e�._-. l '�%( roof assembly is required.
NO ❑ Initial I.C.B.O.q
ADDRESS EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
TO BE REMOVED TO 8E RETAINED
NAME
ADDRESS
CITY&ZIP((�, J ^� / / y� JEXISTING
PHONE 7 D JCO S 2-6-7 /�r/ BUILT-I
ROOFLICENSE
-❑ ����
NUMBER ASPHALT SHINGLES ❑ 7
- LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter g(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
affect. WOOD SHINGLES ❑
License Class - .3( Llc,Number 9
l� p OTHER(SPEMItjYJ� ❑
Date Contrector
OWNER-BUILDER DECLARATION V $�� Iy pp
I hereby affirm that I am exempt from the Contractors License Law for the Ioliowing reason, PROPOS&
/ /1NSrU
(Sec.7031.5,Business and.Profoseeons Code: Any city or county which requires a permit to V V
construct,alter,Improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions b ❑
of the Contractors License Law(Chapter a(commencing with Section 7000)of Division 3 of the CII 1 Vf' 4
• Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT Si4W6 f='S� V ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).):
1CI1,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.
sions Code:The Contractors License Lew does not apply to an owner of property who builds orImprWOOD SHINGLES ❑ /
such Improvements
thereon,and who does such work himself or through his own employees,improvement provided that
such Improve mentaare not Intended or ownetlforedea.11,however,thebuildingof proving
oiImprovement
Is not ld bull or
provene r of for purpose
s the owner-builtlerwill have the burdenof provingtoot he dltl OTHER(SPECIFY)
not build or Improve far purpose of eels.).
]I,as owner of the property,am exclusively contracting with licensed contractors to construct CM
the project(Sec.7044,Business and Professions Coda: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 Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
C]I am exempt under Sec. ,B 8 P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Q' �D/� Building 13-1
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 7 /7 V O
permit is issued.an 7 —/7�� C Seismic ( o
❑I have and will maintain Workers f the work
for Insurance,as required by Section 3700's 7-
Carrier
Labor Coda,for the performance of the work for which this permit IS Issued.My Worker's Total Company Insurance cerrle/antl Policy, umber r
Carrier ��6�F / oilcy Nt�Y�Ss: ��/ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 tl
(This section need not be completed it the permit Is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit is Issued,I shall nol employ l D
any person in any manner so as to become cl to Ihr7 Compensation 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 Applicant — inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,atter making t s Minos a of Exemption,you shoed become Applicant understands and will comply
subject to the Workers'Compensation provieeon the Labor Code,you must forthwith comply ply with all non point
with such provisions or this permit sholljbe deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information Is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and A Iroof covering be class 4or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection 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 Said City In consequence
of the granting of this permit. SONATURE OFAPPILICANT D T
• 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