R 6052 PERMIT R_ 6052
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (409)777-9228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME f[� ,(J [� GJ (/ VES ❑ If yes—assembly
is req that a Class A
!/ roof assembty is required.
!y Fj M1 /� NO ❑ Inigal I.C.B.O.M
ADDRESS 1 /f " / / , y2 / /'BIZ-00k-44 Q %7 EXISTING ROOF COVERING ,
PHONE _ NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP V
EXISTING
PHONE i2BUILT-UP ROOF ❑ /
LICENSE
SHINGLES42— [�
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and
effect.
WOOD SHINGLES ❑
License Claes Lic.Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's License Lew 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 ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
• of the Contractor's License Law(Chapter a(commencing with Section 7000)of Division 3 0l the
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 70315 by anyapplicant for a permit subjects the applicant to
e civil penalty of not more than live hundred dollars($500).):
C]1.as owner of the property,or my employees with wages as their sofa compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractor's License Law dose not apply to an owner of property who builds or WOOD SHIN Lp$
Improves thereon,and who does such work himself or through his own employees,provided that I �J E ❑
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY 0 ❑
not build or Improve for purpose of sale.). 1�r
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct �Cj� sx
the project(Sec.7044,Business and Profess one Code:The Contractor's License Lew does not PRO f jL�S'O. EPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(e)licensed pursuant to the Contractor's License Lew. PROVIDE�Jp1F.GR}IN$`fALLATION SPECS.
❑1 em exempt under Sec. ,B 8 P.C.for this reason VI f 1
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, "� BDlldln3-7
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this '� ar g �0
pe m Is veanissued. 3 3 Seismic
I have and will the pert Worker's Compensation Insurance,as required by Section 3]00 of
t Labor Code,for ins performance of the work for which this permit le Issued.My Workers ^
Compensation Insurance carrier and Policy number are: Total D
Carrier Policy No. d -19Z PERMIT AUTHORIZATION DATE
CERTIFI E OF EXEMPTION FROM WORKERS' _
C MPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit Is for one hundred dollars($100)or leas.)
I certify that In the performance of the work for which this permit Is Issued,I shell not employ � Q
any person in any manner so as to become subject to the Workera' ompensatlon Laws of C All roofs shall be inspected prior to any roofing mat vial being
fornia. f installed. If a roof is installed without first obtaining an
Date fill 4,4 � inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making ffilo Certiflcet of E mption, sho come A hcant understands and will cora
subject to the Workers'Compensation provisions of the L r Corte,you m t forthwith comply PP ply with all non point
with such provisions or this permit shall be deemed revoked. - Source regulations.
I certify that I have read tris 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 coverings to be class° .tier.
hereby authorize representatives of this city to enter upon the above-Mentioned property for In-
spection purposes. l
(We)agree to save,Indemnify and keep harmless the City at Cupertino against liabilities,
judgments,costa and expenses which may In any way accrue against said Clty In consequence
Of the granting of this permit. SIGNATUfl APPLICANT DATE
PRE-INSPECTION: PLYWOOD: - 11,1-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