R 6220 PERMIT R_ 6220
.
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
•. BUILDING ADDRESS 180 DAYS FROM LAST CALLED INSPECTION.
} DSl o-v e m g� 12 1]2
RESIDENTIAL COMMERCIAL OTHER
OWNER'Syes—[
- HAZARDOUS FIRE AREA
NAME �� 1 I ' C � e� YES ❑ II yes—1 understand that a Class A
Mt assembly Is required. _
NO ❑ Initial I.C.B.O.#
ADDRESS DV C V-, b-*7 �� . EXISTING ROOF COVERING
PHONE L ( I I NUMBER OF EXISTING COVERINGS
CONTRACTO 'S
NAME TD)1)—" - ��11 / `1 PFG TO BE REMOVED TO BE RETAINED
ADDRESS /1 �./{ TYPE OF ROOF COVERING
CITYBZIP I SLI_" 1-��
EXISTING
PHONE �(c^� 3 BUILT-UP ROOFLICENSE
❑
NUMBER J ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby a#Irm that I am licensed under provisions of Chapter g(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 �� � Us.Number �����
Data -� ^Z t —`j`b Contractor OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's License Law for the following reason.
(Sac.7031.5,Business and demolish,
or rep it any Any city or county which requires a permit e
construct,eller,Improve,to file signed
n d statementrthat he prior license Issuance,pursuant
also requires the BUILT-UP ROOF ❑
applicant for such pecan a Ill.a signed statement that g it licensed pursuant to the provisions
Of the ss and tPro License Lew(Chapter h(commencing with omSectionand 7000)of Division 3 0l the -�
• Business end Professions Code)or that he Is exempt therefrom end the basic for the oil
aged ^ SPH
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 do is
($500).):
❑l,as owner of the property,army employees with wages as their sole compensation,will do V 00 S KES9 Elthe work,and the structure Is not Intended or offered for sale(Sec.7044,Buslness and Profes.
sions Code:The Contractors License Law does not apply to an owner of property who builds or We��..i).l�x��. I ❑
Improves thereon,and who does such work himself or through his own employees,provided that aGi `-r/`fpgiJ�O i
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
is sold within one year of complain,the owner-builder will have the burden at proving that he did SPECIFY
OTHER
not build or Improve for purpose of sale.). rn (SPECIFY) ❑
01,as owner of the property,em exclusively contracting with licensed contractors to construct Y
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not .REP RT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractorts)licensed pursuant to the Contractor's License Law. PROVIDE MFG R.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
'
I 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 Compensation, Building
as provided for by Section 3700 of the Labor Code,for the perlormanco of the work MUn
r which this g
permit is Issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of /O O Seismic
the Labor Code,for the performance of the work for which this permit Is issued.My Workers Q rye
Compensation Insurance carrierandPolicy number are: ) Total ? 0
Carrier F!/l 1 s) Policy No. I Z� d3_ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N,C.0 p
(This section need not be completed If the permit Is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit is Issued,I shall not employ vVVUJJ
any person in any manner so as to beconleeb t to the workers compensaflon Laws of call- All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date JQ ^z ( -11K Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become
subject I.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 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 state laws relating to building construction.and All roof coverings to be class gor better.
hereby authorize representatives of this city to enter upon the above-mentlaned property for In.
spection purposes.
(We)agree to save.indemnify and keep harmless the City of Cupertino agalnat liabilities,
judgments,costa and expenses which may In any way accrue against said City In consequence
. of the granting of this permit. SIGNATURE 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
OFFICE COPY