R 6092U
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PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R_ 6092
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
I' '
/033/LocC'i." 'e Qom,
RESIDENTIAL COMMERCIAL OTHER -
OWNER'S
HAZARDOUS FIRE AREA
, T
YES E] If yes - I understand that a Class A '
NAME L-�/Ar� I +f V `
roof assembly is required,
NO ❑ Initial I.C.B.O. N
n
ADDRESS
EXISTING ROOF COVERING
PHONE �s7— �Slo d
NUMBER OF EXISTING COVERINGS _ 15rr//
G.
CONTRACTO
a
TO BE REMOVED TO BE RETAINED
NAME r Rn+xi... SG✓ ern ..-ter
C�/
ADDRESS?o
TYPE OF ROOF COVERING
_
CITY 8 ZIP 1J / 5_.
EXISTING
Z/,9®/lJ'p %
PHONE, 2.5�
BUILT-UP ROOF ❑
LICENSE
NUMBER 72,,1, 3
ASPHALT SHINGLES E]
LICENSED CONTRACTORS DECLARATION
- I hereby affirm that I am 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.
c,
License Class �3 / u
WOOD SHINGLES ❑
Llc. Number
Data �� Contractor �"r�
OTHER (SPECIFY)
OWNER -BUILDER DECLARATION
hereby
/
affirm that em exempt from the Contractor's License Law for the following reason.
,PROPOSED `
(Sec. 7ct, alt Business and demolish, or rep Code: Any city or county which requires requires permit to
eny prior lolls issuance, the
constract,or Such prove,ermit
BUILT-UP ROOF ��
t edea signed staair
mentthate,
applicant for cath permit to Iiia a signed statement that to theprovi
it licensed pursuant to the provisions
of the License Lew (Chapter S (commencing with Section 7000) of Division 3 of the
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Business and
ss an Pro Code) or that he is exempt therefrom and the bass for the
ASPHALT SHINGLES ❑
violation of
exemption. Anyviolationof Section 7031r byanyapplicantfora permit subjects the applicant to
applicantto
a civil penalty o1 not more than five hundred dollars (h ):
❑Irks wner employees
oyaeered wages(.their sole compensation,sndPolltlo
wag
WOOD SHAKES
and structure
the work, antl the structure ie not intended or offered for Bale
i not i tmy ended Business end
n owner of wilds or
alone Code: The , Contractor's License Law does not apply toenownerofproperty whobuildsWOOD
improves thereon, and who does such work himself or through his own employees,
SHINGLES ❑
such improvements are not or for leer. however, the building or improvement
improvement ant
owner -builder ill
awnarbuieeer win have the burtlen of proving mat he dm
not ld pr
or onayeaor
OTHER SPECIFY
(SPECIFY)
bull pucompletion,posofsthe
not bulltl or Improve for purpose of sale.).
❑
❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Cotle: 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,
C11 am exempt under Sec. ,B & P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compensation,
as for by Section 3700
BUlldln `
provided of the Labor Code, for the performance of the work for which this
. permit Is Issued.
O -O O
g
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
Seismic r.
the Labor Code, for.the performance o1 the work for which this permit Is issued. My Workers
♦/
Dr yO
Compensation Insurance_ carrier and Policy number are:
Total G_ U O 2
Carrier ?E �/J P.IIcyNo. /37379-7
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need not be completed if the permit is for one hundred dollars ($100))qW lace.)
I certify that In the performance of the work for which this permit Is issued, I shall not employ
All roofs shall be inspected prior to any roofing material being
any person In any manner so as to become subjeJtothorkers'Compensation Laws of call-
lornia.installed.
If a roof is installed without first obtaining an
Date 8 Applicant
inspection, I agree to remove all new materials forinspection.
NOTICE PLICANT: If, akarmaking Ihle xampllon, you should become
subject to the Workers'Compensation provisior Cotle, you must forthwith comply
A licant understands and will tom I with all non oint
PP comply P
with such provisions or this permit shall be d ed rev
source reg TIS.
I certify thetl have reatl tole epplicatlon lid stateI a above Information le correct, I agree
to comply with all city and county ordinances and slat a. Welling to building construction, and
All roof ver' gs to be class "C"or better.
hereby authorize representatives of this city to enter upon the above•mrntlonrtl property for In-
spection purposes.
(We) agree to save, indemnity and keep harmless the City of Cupertino eyalnst liabilities,
In way accrue
L 6
judgments, costs and expenses which may any against Said City In consequence
of the granting of this permit.
SIG F APPLICANT E
PRE -INSPECTION: W
PLYWOOD:
IN -PROGRESS:
INSP. DATE
INSP. DATE
INSP. DATE
TEAR OFF INSPECTION:
BATTENS: -
FINAL:
INSP. DATE
INSP. DATE
INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY