R 6136 PERMIT R_ 613 6
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (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 / ',1p
r w \ I,/>`'�. RESIDENTIAL COMMERCIAL OTHER
OWNERS HAZARDOUS FIRE AREA
I YES ❑ It yes—I understand that a Class A
'NAME ✓ ,S�l�\ \ N roof assembly is required.
/ /� NO ❑ Initial I.C.B.O.If
ADDRESS l/oy J6jf 4(&t4,o � EXISTING ROOF COVERING
�
PHONE p�, -3" / ` O NUMBER OF EXISTING COVERINGS B��
CONTRACTOR'S
NAME TO BE REMOVED TO BE RETAINED
ADDRESS r. ` TYPE OF ROOF COVERING
CITY&ZIP
! EXISTING
PHONE�To �b BUILT-UP ROOF ❑
LICENSE /
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION G
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 lull force and
effect.
License Cl ` 3 uc.Number y 06 WOOD SHINGLES D
OTHER(SPECIFY) OCT �I
Data Cgniractor f7"
nn
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF B ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions Y
at the Contractors License Law(Chapter 8(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 ASPHALT SHINGLES
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).): WOOD SHAKES 01,as owner of the property,or my employees with wages as their sola compensation,will tla ❑
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Profes.
sions Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.ll,however,the building or improvement
IssoId within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Prolssellons Code: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(;)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION'SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner oats
WORKER'S COMPENSATION DECLARATIONAPPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the fallowing declaration: ' —
❑I have and will maintain a Certificate of Consent to self-Insure for Worksre Compensation, ,,,��� Building
aermitI Is forty Section 3700 of the Labor Code,for the performance of the work for which this I //,O,S
Permit Is Issued. /V/ U Seismic �Q
ve La bave and will the performance
Worker's Compensation Insurance,as required by Section Workers of
rihe Labor Coda,tar the performance of the work for which this permit Is Issued.My Worker's 9 Total
camps it Insyrence carrier antl Policy number are: %(/� yl —P/ e
CarrierS�1T G Uw dt• Policy No. V O( PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N10,o 101
(This section need not be completed If the permit is for na hundred tlolleralk
0)or leas.)
I certify that In the performance al the work for whit permit Is' suep, _II not ample
any parson In y man r so ea to became subject t arkere• moan; en L_ws of - All roots shall be inspected prior to any rooting material being
torn'a. Id installed. If a roof is installed without first obtaining an
Date Applican inspection,I agree to remove all new materials for inspection.
subject toothe orkereCCompef,alier me naetlonprovielonlsoltheLebo f tla,Ytl��',yiaie nwnh000me Applicant understands and will comply with all non point
with such provision;or this permit shall be deemed revoked. source regulations. -
I certify that I have read this application and state that the above Information is correctI agree
to comply with all city and county ordinances and state laws relating to building construction,and All Too coverings to be "C"orb er.
hereby authorize representatives of this city to enter upon the above-mentioned property for In- /�
spection purposes. fe
(We)agree to save,indemnify and keep harmless the City of Cupertino against Ilabllllles,
judgments,costs and expenses which may in any way accrue against said City In consequence
' al the granting of this permit. SIG RE-OF WLICANTZ 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY -