R 6015 PERMIT R_ 6 15
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
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BUILDING ADDRESS 180 DAYS FROM LAST CALLED INSPECTION.
•n/ '
0 �Q RESIDENTIALI�/COMMERCIAL OTHER
OWNER• _ - HAZARDOUS FIRE AREA
,f, - YES ❑ It yes—I understand that a Class A
NAME III... I root assembly Is required.
O ❑ Initial I.C.B.O.#
ADDRESS pEXISTING ROOF COVERING
PHONE
p Z L2, NUMBER OF EXISTING COVERINGS dam'
CONTRACTOR' `^V (\��
NAME TO BE REMOVED TO BE RETAINED
ADDRESS 'G �� rel 1 �I ) w TYPE OF ROOF COVERING
CITY&ZIP I LL
4 7
EXISTING
BUILT-UP ROOFLICENSE
❑
NUMBER L2 ASPHALT SHINGLES ❑
' LICENSED CONTRACTORS DECLARATION - \
1 hereby affirm that em sin licensed under Professions
loss of Chapter B(commencing calif Section WOOD SHAKES
70 00)of Division 3 0l the Business and Pro/eaelona Code,and my license is In lull lone and
een.
Li _ WOOD SHINGLES El Cle Lia.Number '
Dale contractor OTHER(SPECIFY) ❑
OWNER-BUILDERfromthContractors
DECLARATION PROPOSED
I hereby affirm that am exempt from Professions the e: Anytofs License Lew for the uires a rmit t.
(Sec.7031.5,Buelneee entl olish.orreCode: Any city or county which re,also a permit to
conac ntforsuchpermittofile signedstaeny mentrthathep licenseor to Its Issuance,elstheproviathe BUILT-UP ROOF ® ❑ / 'D/
applicant for such permit to Ills a signed r 0(commencing
that g i hcen do pursuant to the pro of the
of the Coniraetore License Lew(Chapter 8(commeneing 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 SHINGI ii
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a clvll penalty of not more than five hundred dollars($500).):
C]1,as owner of the property,or my employees with wages as their Bole compensation,will do WOOD SHAKES
the On,and the structure Is not Intended or offered for sale Sec.7044,Business and Protea- ``r
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLEOC4
employees,provided that ❑
Improves thereon,entl who does such work himself or through his own J
such Improvements are not Intended or offered for sale.If,however,the building or Improvement <
to sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER (SPECIFY)G\
\�J El
build or Improve for purpose of sale.).
0I,es owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Profess he
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.
❑I am exempt under Sec. ,B&P.C.for this reason
Owner oats
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
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hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-insure for worker's Comp%satloI,e Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for welch th
permit le Issued. U I 75Jf l� Seismic /
❑ have and will maithe performance
Worker'&Compensation the wokfor Insurwhich this as required by Section 3700's v �/
,the Labor Code,for the penmmand of the work Ira which this permit Is laeuetl.My Worker's Total /7 �, D,0
Compensation Insurance carrier entl Policy number are: � n '
Carrier / coy .t-frr— Pollcy No. I�� 6 2— PERMIT AUTHORIZATION DATE
4 CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If the permit is for one hundred dollars($100)or lees.) f5_,6 Clfi z(-r
- I certify that in the performance of the work for which this permit is Issued,I shall not em toy
any person In any manner so as to become subject to the Workers'Compensation Laws of�ml- All roofs shall be inspected prior to any roofing material being
fornia. installed. It a roof is installed without first obtaining an
Date Applicant inspection,l agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,she(making this Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shalgbe deemed revoked. Source regulations.
I certify that I have reed 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 All roof c0 Brings to be class• or better.
hereby authorize representatives of this city to enter upon the above-mentlonad property for In. /
spection purposes.
(We)agree to save,expenses
and keep harmless was iha Clry of Cupertino against liabilities, r
ofCq
the gran coats and permit. a which may In any way accrue against said Clry Inconsequence
1,10 of the granting of this permit SIG URE OF APPLICANT 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
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