R 6088 PERMIT R,; 608 8
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
�. BUILDING180 DAYS FROM LAST CALLED INSPECTION.,7/ lADDRESS - � �-
G�1.b'T •O�—I Y� L,�;
aRESIDENTIA COMMERCIAL OTHER
OWNER'S y�k/�r (� \ it
FIRE AREA,
'NAMEC'7�`� s-' `CvUrCN EO�+ VES ❑ IFyes—I understand theta Class . ,
root assembly is required.
�` NO Initial I.C.B.O.W-
ADDRESS Z.(a7 J Q C I VE Ay.. EXISTING ROOF COVERING
PHONE
g -,q5'�� NUMBER OF EXISTING COVERINGS -
CONTRACTOR'S
.,TO BE REMOVED TO BE RETAINED
NAME
ADDRESS - - TYPE OF ROOF COVERING
CITY&ZIP_ - EXISTING
.PHONE e _ _ BUILT-UP ROOF ❑ - '
LICENSE
NUMBER ASP SHI
LICENSED CONTRACTORS DECLARATION ,Q
I hereby affirm that I am licensed under provisions of Chapter S(cdm Ith•Sectlon WO HA K S
7000)at Division 3 of the Business and Professions Code,and my Ilcense' a anti D
effect.
W DS x.71998
License Class 'Uc.Number Or -
O }R(SPECIFY) El
'Contractor - -
OWNER BUILDER DECLARATION PR PO
' I hereby u81rm that I am exempt from the Contractor's License Law for the tollowin a ,
(Sec.7031.5,Business and Professions Code: Any city or county which requires a er t° -
construct,alter,improve,demolish,or repair any structure,prior to its Issuance.also requires th BUILT-UP ROOF ❑ - -
applicant for such permit to file a signed statement that he Is licensed pursuant to the provision `
• of the Contractor's License Lew(Chapter 0(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
a civil penally of not more than five hundred dollars($500).): -
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ,
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes.
sides Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES Elimproves thereon,anti 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 '
is sold within one year of completion,the owner-builder will have the burden of proving that he didOTHER(SPECIFY) - ❑
not build or improve for purpose of sale.). -
1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sac.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply t0 an owner of property who builds or improves thereon,and who contracts for such projects
with a contractogs)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B&P.C.for this reason
owner oats APPLICATION DATE VALUATION ' PERMIT FEE
WORKER'S COMPENSATION DECIARATION ,
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 Walker's Compensation,
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
per[-Jlhaissued.
t S81S ¢Q1 cd
❑ hevo and will maintain Worker's Compensation Insurance,as required by d.My
3700'of
s - ► L 1T
the Labor Code,for the Performance of the work for which ihl9 permit is issued.My Worker's '
Compensation Insurance carrier and Polley number are: - Total
Carrier Policy No. PERMIT AUTHORIZATION DATE
- CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE N.C.O
(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, shell not employ
any person in any manner s°as to become subject to the Workers'Compensation Laws of Cali. All roofs shill be Inspected Prior t0 anVi,,ffoting mateftTteing
0f"18' installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection:
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply p Y p
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 Allroof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes. - -
nNe)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 Ci
of the granting of this permit. ry In consequence GNATUOF APPLICANT DATE
.,•, PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE' INSP. DATE INSP. DATE
TEAR OFLLNNVECTION: C BATTENS: - FINAL: -
INSP. r DATE� Z L� INSP. DATE INSP. DATE
NOTE: OSHA-APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY