R 6132 PERMIT R_ 613 2
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
100 DAYS FROM LAST CALLED INSPECTION.
. BUILDING ADDDRRESSSS
� 1 ' `^-'1 \iia-C RESIDENTIAL COMMERCIAL OTHER
OWNER'S /�/� r� ,r- ,�.y�y'� HAZARDOUS FIRE AREA
NAME— �Tno I• W { � T1� 1 o ' VES ❑ If yes-I understand that a Class A
roof assembly is mcluted..
I NO Initial I.C.0.0.It
_ ADDRESS �1JV\ � --r �1 Q,C�i EXISTING ROOF COVERING
PHONE o' ! ' NUMBER OF EXISTING COVERINGS �„J f �n•-�
CONTRACTOR'S
NAME TO BE REMOVED TO BE RETAINED
"��,�111111_...11// r V
ADDRESS r� l, l. � 1 „ Q1 � �y TYPE OF ROOF COVERING
CITY&71P oL "f �/r T l 1 L�t.�.
14b8- 3W9 -I b EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE 1
NUMBER l Q r!yF.J ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions at Chapter a(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 Close Lic.Number
Data -a 19 a Conireclor
OTHER(SPECIFY) ❑
OWNER-BUILDER DE TION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law lar the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires permit to
construct,after.Improve,demolish,or repair any structure,prior to Its I re ulna the BUILT-UP ROOF
applicant for such permit to file a signed statement 1 e p s ant to ovisions
• of the Contractors License Law(Chapter B ening action 7 0 1 of D 3 of the
Business and Professions Code)or that'It ampt t e and t eels 1alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 appll or armitsublactslh a (cant to
a civil penalty of not more than five hundred 11 ($500)) y�r� ❑
I]1,as owner of the property,or my empt Ith,Lv�gpp�(gplefi�ol{ap$�an ti will do WOOD SHAKES
the work,and the structure is not Intended o ff ad I S66cc fitEE4Amr`•B�SSsi-news notes.
the
The Contractor.License Law tl nota IyyTTto an owner of property to Idsor WOOD SHINGLES
Improves thereon,and who does such work hl elf or through his own employees,provid d that ❑
such Improvements are not Intended or offers r sale,If,however,the building or Impro ment
is sold within one year of completion,the owns builder will have the burden of aditl OTHER SPECIFY
not build 1,as
Improve for purpose of seta.). (SPECIFY) �
❑Lee owner of the property,am exclusive cenetls License
Law does
the project ownerf pr Business and Profess Imprssthe:7ne Contractor'slicense Law doesnot PROVIDE LC.B.O.REPORT NO.
apply to c ntownerof property who balite orImproVeathereon,and who contracts for such projects
with a c m exemptracti licensed pursuant to the Contractor's license Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,B 8 P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: 3o O
❑I have and will maintain a Certificate or Consent to self-insure for Worker's Compensation, Building
as provided for by Section 3700 a1 the Labor Code,for the performance of the work for which this / g
rml Issued. Seismic -/ `�
I have end w111 the performance
Worker's Compensation Insurance,as required is I su Section 3700 or n�t11 Il`� ✓f
ih or Code,for the performance the work for which this permit is Issued.My Worker's 3 mQ 2 x(� p
pensatlon nco it oIcy sere: �/Q �/��)f��./� Total
Carrier Policy No. 113 L t PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C. ]
(This section need not be completed If to permit Is for one hundred dollars($100)or less.) t (>
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 become subject to the Workers'Compensation Laws of can. All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof Is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO PLICANT: this Certificate of Exemo
subject to the Workers'Compefnsation provafter isions of the Labor Code,yo'u must forlhw'hbecome comply 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 ordinances and slate laws plating to building construction.and All verings to be OEIss Orb tier.
herby authorize representatives of this city to enter upon the above-mentioned progeny for im
hereby
purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
jutlgmenta,coats and exponses which may In any way accrue against said City In consequence
or the granting of this permit. SIGNATURE OF APPLICANT' ATE
• PRE-INSPECTION: PLYWOOD: - IN PROGRESS:
INSP. DATE INSP. DATE INSP-DATE—
TEAR
NSP. DATETEAR OFF INSPECTION: BATTENS: FINAL: _
INSP. DATE .INSP. DATE INSP. DATE
NOTE: -OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY