R 6320 PE
APPLICATION FOR CITY OF CUPERTINO NUMBER R-. 632
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REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS
180 DAYS FROM LAST CALLED INSPECTION.
( 1
O L�j/vJe4.tje—. RESIDENTIAL COMMERCIAL OTHER
OWNERS
� - HAZARDOUS FIRE AREA
NAME -1` (• V� `-EL� YES ❑ If yeaI understand thatClaw A
T4
roof assembly is required..
NO I] Initial I.C.B.O.#
ADDRESS to 22�'7 �✓���'11 4 . EXISTING ROOF COVERING
PHONE 7 — O jp NUMBER OF EXISTING COVERINGS
CONTRACTO
7
NAME -)`� [rir� O ,(/ — TO BE REMOVED /� TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY 8 ZIP
EXISTING
PHONE BUILT-UP ROOF ❑
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 8(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 Lie.Nu,�
Date _ y Centr4alo� u - OTHER(SPECIFY)
-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exam Ir m tt�gff�xgpgqttreEEptor' LI [[99w� r. following reason.
(Sec.7031.5,Business and Prof,1 one Qpy6:YAn�dort0wh h quires a permit to
construct,alter.Improve,demobs rrepafrany structure,prior to its las also requires the BUILT-UP ROOF ❑
applicant for such permit to life e I ad statement tnet he ie Ilcensetl p t to the provisions
of the Contractor's License Law( hrar1p�ter B(commencing with Section 7000) I Dimillon 3 of the
• Business and Professions Code) tl8qt he Is exempt therefrom and the le for the alleged ASPHALT SHINGLES
exemption.Any violation of Sadlo 1 ets the applicant to
a om enalty of not more then fiv trrmdree
I,es owner of the property,or my employees with wages as
their Joe
e compeneellon,will do
WOOD SHAKES ❑
I
work,and the elructum le not Intended or offered for seta(Sec.7044,Outlines.antl Profae-
elons Code:The Conlrector's Lieense Lew dose not apply to en owner of property who build.or WOOD SHINGLES Improves thereon,antl who tlaas such work himself or through his own employees,prdvitled that ❑
won Improvement.are not Intentletl or offered for sale.ff,however,the bulltling or Improvement
to
sold within one year of completton,the owner-bulldm will have the burden of proving that he tlid OTHER(SPECIFY) ❑
not bulid or Improve for purpose of eat.)
I,as owner of the property,am exclusively contracting with licensed contractors to construct
the projed(Sec.7044,Business and Professions Code;The Contractor's License taw 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 contrecer(s)licensed pursuant to the Contractor's License Law.
❑I ee pt nl�tler ,B 8 P,C.for this reason PROVIDE MFGR.INSTALLATION SPECS.
owner ate
WORKER'S OMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penally of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, Building
/O 7
as providod for by Section 3700 of the Labor Code,for the performance of the work for which this n
permit is Issued
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of v Seismic//��10�'
the Labor Cotle,for the performance of the work for which this permit Is Issued.My Worer'a Total [Q7r n�
Compensation Insurance carrier and Policy number are:
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 100)o
(This section need not be completed If
COMPENSATION
permit Is for one hundred dollars($100)or IeeaJ `l/ (/ 6A�
I certify that In the performance of the work for which this permit Is Issued I shall not employ '
any person In any manner so as to bsee o subje t to the Worker'Comps n Lew.a can- All roofs shall be inspected prior to any roofing material being
fornix. �p installed. If a roof is installed without first obtaining an
Dote f�(=[d nppnca , inspection,I agree to remove all new materials for inspection.
NOIsubject to the Workers'Compefnsation provisionls of thefiLabcateor Code ,yolu mustf Examn, ufo thwitlhbcomply Applicant understands and will comply with all non point
with such provisions or this permit shall be 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 ordinancesend state laws relating to building construction,and All roof coverings to a class A.or 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 aBulnst liebllitlee, r l
judgments,costa and expenses which may in any way accrue against said City In consequence
. of the granting of this permit. lief SIGNATURE F PLICANT DATE
PRE-INSPECTION: PLYWOOD: N-PROGRESS:
INSP. DATE INSP. DATE INSP.-DATE
. TEAR OFF INSPECTION: BATTENS: INAL:
INSP. DATE INSP. DATE INSP.-DATE.
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY -