R-6608 PERMIT R_
APPLICATION FOR / CITY OF CUPERTINO NUMBER 6608
REROOF PERMIT �020 INSPECTION408777-3228 PERMIT EXPIRATION
408 777-3228 PERMITPIKES IF WORK IS NOT STARTED
WITHIN 180 SODAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
�o�so 6'� �d a ✓
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
VES ❑ II yes—I understand that a Class A
roof assembly is required.
Xn-1 �MZ/nL[/ NO ❑ Initial I.C.RO.If
-
ADDRESS- /,�0 ,r' EXISTING ROOF COVERING -
PHONE ( (v�o) 9/o33G NUMBER OF EXISTING COVERINGS
CONTRACTOR'S a
TO BE REMOVED � TO BE RETAINED
NAME
TYPE OF ROOF COVERING
ADDRESS
CITY s ZIP EXISTING
PHONE BUILT-UP ROOF Q
LICENSE ��a73i ASPHALT SHINGL D Q
NUMBER
LICENSED CONTRACTORS DECLARATION I' D
I hereby affirm that I am licensed under provisions of Chapter 9(commencing w11h S I WOOD SHAKES JUN 1IV1999
7000)of Division 3 of the Business and Professions Code,and my license Is in full for d J J J
effect' WOOD SHINGLE ny ❑
License Claes G,39 Lie.Number B
HER(SPECIFY)
Date Contractor
OWNER-BUILDER DECLARATION PR ED
I hereby affirm that I em exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Cade: 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 El
for such permit to file a Signed statement that he Is licensed pursuant to the provisions
of the Contractors License Lew(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he is exempt therefrom and the bests for the alleged ASPHALT SHINGLES [�
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 dollars($500).): WOOD SHAKES El
I,as owner of the property,or my employees with wages as their sole compensation,will do
the work.and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
aionsCode:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
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
Is Sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,em exclusively connecting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to en owner of property who bullds or improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
I am exempt under Sec. ,B B P.C.for this reason
Owner Dale 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 self-Insure for Worker's Compensation, j Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this T /Z 7. �J/f
permit is Issued. qpD,G� Seismic 7 N
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,Aor the performance of the work for which this permit Is Issued.My Worker's Total
CampeisilifforlyAuTnce carrieKh d Policy number are:
carrier Policy No. AAP LlP9nL� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE T1 ^^
(This section need not be completed If the permit Is for one hundred dollars($100)100)or lees.) Y
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 Cali- 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.
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 previsions of the Labor Cotle,you must forthwith comply
with such provisions or this permit shell be deemed revoked. Source regulations.
I coldly 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 fAngses ' or 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, L
judgments,costs and expenses which may In any way accrue against said Ciry In consequence IGNATUFTE OF APPLICANT 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
OFFICE COPY