R 6271•
•
APPLICATION FOR
REROOF PERMIT
NAME___ M r �144,tV
ADDRESS 7-ZZ7�- G 6
PHONE 7'74 ' 7o 4,
NAME 42r— 4,o x144
CITY OF CUPERTINO NUMBER R— 6271
INSPECTION DIVISION PERMIT EXPIRATION
(408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STAR1
ADDRESS
CITYBZP �DO "'Q'��¢,G�S ��i✓jd5 Np�Z
PHONE (iti)
LICENSE
NUMBER
I hereby affirm that I em licensed under provisions of Chapter 0 (commencing with Section
7000) of Divlelon 3 of the Business and Professions Code, and my license Is In lull force and
effect.
License Claes Lic. Number A7,,}Iff
Date �— 36 �b0 Contractor F rc.00<
OWNER -BUILDER DECLARATION
I hereby affirm that I em exempt from the Contractors License Lew for the follo'ieg reason.
(Sec. 7031.5, Business and Professions Cade: Any city or county which requires a permit to
construct, alter, Improve, demolish, or repair any structure, prior to Its Issuance, also requires the
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Lew (Chapter g (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he Is exempt therefrom and the basis for the alleged
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not mare than live hundred dollars (§500),):
Cl 1, as owner of the pro r ormy employees with wages as their sole compensation, will do
the work, entl the atruclur le nBtYnWOQetl or offered for sale (Sec. 7044, Business and Profes.
sions Cotle: The Contract es, cense lei$ not apply to an owner of property who builds or
Improves thereon, entl w /dgde such w�tk Nmeelfp.tbrouah his own emoloveee. orovltlatl that
the
❑ I am exempt
to construct
w does not
,B S P. C. for this reason
owner Date
WORKER'SC DECRATION
1 hereby affirm under penalty of perjury one of the doclaration:
❑ 1 have and will maintain a Certificate of Consent to sell -Insure for Workers Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
per tis issued.
I have and wlll maintain Workers Compensation Insurance, as required by Section 3700 of
t or Cotle, lar the performance of the work for which this permit Is issued. My Workers
Compensation Insurance cerrler e�n/tlfalloy number ere: i'
Carrier �G 6'y'� Policy No._ -i " /0G3416' —9z
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.F1
(This section need not be completed It the permit Is for one hundred dollars ($100) or lase.)
1 certify that in the performance of the work for which this permit Is Issued, I shell not employ
any person In any manner eo es to become subject to the Workers' Compensation Laws of Cell.
fornix.
Date Applicant
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
with such provisions or this permit shelgbe deemed revoked,
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
hereby authorize representatives of this city to enter upon the above.mentloned property for In-
spection purposes.
(We) agree to save, Indemnify and keep harmless the City of Cupertino against liabilities,
judgments. costa and expenses which may In any way accrue against said City In consequence
PRE -INSPECTION:
DATE
INSPECTION:
RESIDENTIAL COMMERCIAL OTHER
YES ❑ If yes — I understand that a Class A
roof assembly is required.
NO rI Initial I.C.B.O.
NUMBER OF EXISTING COVERINGS
TO BE REMOVED I TO BE RETAINED
BUILT-UP ROOF ❑
ASPHALT SHINGLES
WOOD SHAKES
WOOD SHINGLES
OTHER (SPECIFY)
PROPOSED
BUILT-UP ROOF ❑
ASPHALT SHINGLES ❑
WOOD SHAKES
❑
WOOD SHINGLES
❑
OTHER (SPECIFY)
PROVIDE I.C.B.O. REPORT NO. 3
PROVIDE MFGR. INSTALLATION SPECS.
JAPPLICATION DATE] VALUATION PERMIT FEE I
Buildingill
IZ 7(,p Seismic / 3 O
Total r,43 8
PERMIT AUTHORIZATION I DATE I
installed. If a roof is installed without first obtaining an
inspection, I agree to remove all new materials for inspection.
Applicant understands and �orbette�
with all non point
source regulations.
00 0 ass—/o —Rq
SIGNATURE OF APPLICANT DATE
IN -PROGRESS:
FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
__ _ OFFICE COPY _