R-6495G
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f PERMIT
R' 6 4 9 5
APPLICATION FOR CITY OF CUPERTINO NUMBER .
INSPECTION DIVISION ' PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
' 180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRE�SS
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RESIDENTIAL COMMERCIAL OTHER
'OWNER'S
HAZARDOUS FIRE AREA
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VES ❑ If yes I filet eClass A -
NAME ej/
assembly is req
s
roof assembly is requiredti _
NO' .f(Y Initial— LC.B.Oix =
'EXISTING ROOF • -
/COVERING
NUMBER OF EXISTING COVERINGS `
PHONE —
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'TO
CONTRALTO '_ f \ -
i
TO BE REMOVED r/ BE RETAINED
NAME
TYPE OF ROOF COVERING
ADDRESS �/j
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CITY 8 Tp 76y�
EXISTING
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PHONE
BUILT-UP ROOF.'' .,
,Y��y
LICENSE
NUMBER
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ASPHALT SHINGLES'. -
LICENSED CONTRACTORS DECLARATION - -
I hereby affirm that I am licensed under provisions of Chapter 0 (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 Class Up, Number
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OTHER (SPECIFY)- ❑ '
Datey t
Contracor
OWNER-BUILDERDECIARATION
PROPOSED -
I hereby. affirm that I am exempt from the Contractor's License Law for the following reason.
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(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 Contractors License Law (Chapter g (commencing 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 SHINGLES
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil ponalry, of not more than live hundred dollars ($500).):
do
'
WOOD SHAKES
01, as owner of the property, or my employees with wages as their sole compensation, will
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Pfofes.
.❑
sions Code: The Contractor's License Law does not apply to an owner of property who builds or
WOOD SH INGi,----a -
• Improves thereon, and who does such work himself or through his own employees, provided that
' such Improvements are not Intended or offered for sale. If, however, the building or improvement
i (1 �,-_
- IaaIdwithin one year ofcompletion, the owner -builder will have the burden of proving that he did
OTHER(SPECIFY)� -
not build or improve for purpose of sale.).
If! 11 -
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❑I,asownor of the property, am exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not
PROVIDE, LC.B:O> REPORT,yNO�
apply to an owner of property who builds or improves thereon, and who contracts for such projects
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with a contractors) licensed pursuant to the Contractor's License Law.
PROVIDE-MFGR. INSTALLATION S.
❑ I em exempt under Sac. _ ,B 8 P. C. for this reason
Owner Date
APPLICATIO
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm undo, penalty of perjury one of the following declaration:
❑ I have and will maintain a Certificate of Consent to self -Insure for Worker's Compensation,
for
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as provided for by Section 3700 of the Labor Code, for the performance of rho work which this
P. Is Issuetl.
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I have end will maintain Workers Compensation Insurance, ea required by Section 370001
have
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Labor Code, for the performance of the work for which this permit is Issued. My Worker's
%
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Compensation Insurance carrier antl Polic/yJnumber are:
-
PERMIT AUTHORIZATION
DATE
/l
carder %��Q - %T-FIl/�Na.
FROM
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NAI
o
(This section neednot be completed If the permit Is for one hundred dollars ($100) or less.)
the is Issued, 1 shell not employ
I certify that in the performance of the work for which this Workers'
' any person in any manner so as to become subject to the Workers' campeneatien Laws of coli-
All roofs shall be inspected prior to any rooting 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.
' CE TO APPLICANT: If, after making this Certificate of Exemption, you should become
NOT CE
with. all non
pP understands and will comply p y point
Applicant
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
with such provisions or this permit shalfbe deemed revoked.
Source regulations.
I certify that I have read this application and state that the above Information Is correctI agree
to comply with all city and county ordinances and stare laws relating to building construction, and
All roof Coverings to be glass" Of better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costs and expenses which may In any way accrue against said City In consequence
SIGN E LIC DATE
of the granting of this permit.
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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