R-6620 PERMIT R_ 6620
APPLICATION FOR CITY OF CUPERTINO NUMBER
R-
oZ, INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
otia
�� j� RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES Ela—I understand that a Class A
NAME r ❑ roof assembly is require
NO d
I.C.B.O.k
ADDRESS—130 EXISTING ROOF COVERING
PHONE (Q ( �8 Q NUMBER OF EXISTING COVERINGS
PHONE r&
CONTRALTO � d
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS _ TYPE OF ROOF COVERING
clry a zlP / EXISTING
PHONE ( BU ILT•UP ROOF ❑
LICENSE
NUMBER 731
ASPHALT SHINGLED 4
LICENSED CONTRACTORS DECLARATION .
1 hereby affirm that 1 am 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 full force and J(/N
effect. 639 a273/ WOODSHINGL e
License Class Llc.Number gg
O HER(SPECT \❑
Dale Contractor
OWNER-BUILDER DECLARATION P
hereby affirm that am exempt from the e: Any city orLicensecoup Lew for the following reason.
(Sac.70315,Business and demolish,
or rep Code: Any city or county which requires also a permit to
construct,alter,Improve,demolish,or repair any structure,Is licensed
ic to Its)pursuant also requires the LT-UP ROOF ❑
eppllcent for such permit a flaw a Signed r 9(commencing
That g le Ilce Section
pursuant to the provisions
of the ss and lr Professions License Law(Chapter a(commencing with Section 7000)of for the 3 of the
• Buelneee endviolationof Code)or that he b exempt therefrom and the bases for Ina alleged AS HIN E3 p.
exemption pen.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e cIVII penalty of not more than five hundred yeesrs(h wag): WOOD S S
❑I,as owner of the property,or tmy eemployeeswith wages exec.their 7Bole compensation,will do ❑
the work,and the structure Is not intended or offered for sale(Sac.7064,Business end Proles.
sons Code:The Contractor's 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-bullder 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,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant o the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
1 em exempt under Sec. .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, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this _
permit Is Issued. /I/ /J1 �O $eISfT11C —'L
❑I have and III melnleln Worker's Compensation Insurance,as required by Section 3700 0l / CCS
the Labor Cod r the performs a of the work for which this permit Is Issued.My Worker's /
Comps alio ureneecerriar n Poll` numbner�are:
�f Total
Carrier. O'""`" "-FollcyNo. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(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
any.person In any manner so as to became subject to the Workers'Compensation Laws of Can- All roofs shall be inspected prior to any roofing material being
fornia, installed. If a roof is installed without first obtaining an
Dale 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
with such provialons 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 [B&f coverinas.to be Cl SSS o better.
hereby authorize representatives of this city to enter upon the above-mentioned properly for Ira
spoction
(We)purposes.
(We)agree to save.Indemnity and keep harmless the Clry of Cupertino against liabilities, r�
lutl menta,costa and expenses which may In any way accrue against said City Inconsequence �IATURE OF APPLICANT - DATE
of t�9 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 _ _ _