R 6050L
•
OFFICE COPY
NUMBER R" 60 5 0
APPLICATION FOR CITY of CUPERTINO
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1 S DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
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RESIDENTIAL COMMERCIAL OTHER
OWNER'S V
HAZARDOUS FIRE AREA
/y0l� �//
VES �{f ClassA
NAME /ON-
f00( as58mbh/ IS mGUlfad.
roofIfyiassembly its required
NO ❑ Initial LC.B.O. N
ADDRESS /75744 /��SA� c[f V
EXISTING ROOF COVERING
PHONE O B — 63/gNUMBER
OF EXISTING COVERINGS
CONTRACTOR'S .
/���
NAME l7yONF7 (f&/^
TO BE REMOVED TO BE RETAINED
ADDRESS!/y /�� ��/.
D
TYPE OF ROOF COVERING
CITY&ZIP cT�`'/-
CAS`/Jeo ey -CC
EXISTING
y
BUILT-UP ROOF ❑ .
NUMBER
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter g (commencing with Section
WOOD SHAKES �G]'
7000) of Division 3 of the Business and Professions Code, and my license is In full force and
affect I
[� �1 C (1
License Cl 4 Llc. Number / aPa�j
WOOD SHINGLES ❑
/ u / 8 ptrF v
OTHER (SPECIFY) ❑
�f ,G. _
Date Contractor -
OWNER -BUILDER R N
hereby that I am exempt from the License Lew for the follorequires
PROPOSED
, Buirm
(Sec. 7031.5, Business and e:Contractor'scity t.
Code: Any city or county which requires a permit to
a permit
!� /
or rep
construct, alter, Improve, demolish, anystructure,tat e, prior to pe Issuanca, also requires the
BUILT-UP ROOF 1:1
flaw a
applicant for etch parent to file signed statement
statement that he licensedactio pursuant to the provisions
of the a
Contractor's License Lew (Chapter S
(Chapter it
(commencing with Section 7000) of 3
y
Business end
ss and Is ex for the le ed
Code) or that he la exempt therefrom and the heals roe the sant
ASPHALT SHINGLES ❑
exemption, Any violation of Section
violation of by any ant for a permit subjects the applicant to
to
f
e civil penalty of not more than itva huntlretl tlollere ($500).1:
hundred s ($5
❑I,as owner of the property, or my employees with wages as their Bole compensation, will do
the work, and the structure as not Intended or offered for sale (Sec. 7044, Business and Proles-
WOOD SHAKES ❑
/ T
sions Code: The Contractor's License Low does not apply to an owner of property who bullds or
@X
C
Improves thereon, and who does such work himself or through has own employees, provided that
WOOD SHINGLES ❑
such Improvements are not Intended or offered for sale. If, however, the building or Improvement
Is sold within one of completlon, the owner -builder will have the burden
0
year of proving that he did
not build or Improve for of Bale.).
OTH Ra($
purpose
0I, as owner of the property, am exclusive contracting with licensed contractors to construct
�ECIFY)
-
the project (Sec.7044, Business and Professions Code: The Contractors License Law does not
PROVIDE I. REPORT NO.
apply roanowner olicensd who beidethe Improves thereon,end who contracts for such projects
O
with acomexempt neer Se pursuant to the Contractor's License Law.
� I em exempt under Sec. ,B 8 P. C. for this reason
V GR. INSTALLATION SPECS.
P
,40
Owner
WORKER'S COMPENSATION DECLARATION
ApN P 4 ICATIONbATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ I have and will maintain a CerlKiose of Consent to self -Insure for Workers Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work kr which this
/ I
Building J
permit Is Issued.
❑ have and will Worker's Compensation Insurance, as by Section 3700
�
Seismic
themaintainrt the work for ,
the Labor Cotle, for the performance of the work for whack IMI permit is Issued. MyW�ker'e
permit
Compensation Insurance cerrle�r.ennd Policy number are: 9—/—'y
Total p
CarrierNd PoIIcyNo.�=
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
o/
a
COMPENSATION INSURANCE N.C.p
(This section need not be compared If the permit Is for one hundred dollars ($ or lose.)_
I certify that in the performance of the work for which this permit Is Issued, I skarn not employ
All roofs shall be inspected prior to any roofing Material being
any person an any manner so as to became subject to the workers' Compensation Laws of Can-
fornia.
J
installed. If a roof Is installed without first obtaining an
Data �O /If, Applleam
inspection, I agree to remove all new materials for inspection.
NO o t e APPLICANT: erattar mekang 11he�rfiof Exemption, you should become
to the Workers' Comp tl the Code, you moat forthwith comply
Applicant understands and will comply with all non point
PP p y p
withssubject
or permit h l be
p shell tleemetl tl.
revoked.
with such ghat
SOUfCe regUlatIORS.
I have
certifythat Neve reedountyordiancentlarsethattheabove Information
ad his application that th is correct, agree
to and county tobudng
this city and state lone building and
All root coverings to be class `iii" Or better.
hereby authorize representatives of the o e- d propertyf,
hereby authorize ropreeentativee of this city to enter upon iha shove-mentlonetl property for In-spection
purposes, n
(We) agree to save, and keep harmless the Clry of Cupertino opens Ilebllence W
C
J.costs expenses way
entl expenses which may In any way accrue against said City In consequence
GNATUF APPLICANT DATE
oftva gran
m thw granting of this permit.
of
PRE -INSPECTION:.
PLYWOOD: 0 .
IN -PROGRESS:
INSP. DATE
INSP. LII f DATIJ
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