R-6621 PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMBER R— 66 21
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT 8 5�j (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
_ WITHIN DAYS PERMIT ISSUANCE OR
180DAYS FROM LAST CALLED INSPECTION
BUILDING ADDRESS /
/ 611? /�� ✓ COMMERCIAL OTHER
RESIDENTIAL
OWNER'Sr, _ n HAZARDOUS FIRE AREA
VES ❑ If yes—I understand that a Class A
NAME roof assembly is required.
NO ❑ Initial I.C.B.O.It
ADDRESS /,,() EXISTING
_ �^/ EXISTING ROOF COVERING
PHONE - 9Co U O NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
TO BE REMOVED YTO BE RETAINED
NAME
ADDRESS _ " TYPE OF ROOF COVERING
CITY&ZIP (J
(Q EXISTING _
PHONE �S BUILT-UP ROOF ❑
LICENSE � l -72/ ❑
NUMBER _ oC / ASPHALT SHINGLE
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 em 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
epees G 3 9 1� aa73 WOOD SHINGLE
uc ✓ O
License Class .Number
OTHER(SPECT UN Z 6D
Data Contractor n�
OWNER-the Conn DEC's License
PROPOSED By J
.703 affirm that am exempt from the e: Any city License Law for the fins a reason.
Y P 9
Sec.7031.5 Business and Professions Code: An cit or county which requires permit( y y ry qu ee a ui to
applicanLaltar,Improve,demolish,orrepairanystructure,prior toils Issuance.also requires the BUILT-UP ROOF
applicant for such permit to Ills a signed statement that he Is licensed pursuant t0 th0 provisions
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Dlvlalon 3 of the
• Business and Professions Code)or that he Is exempt therefrom and the beats Tor the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subject.the applicant to
a clvll penalty of not more than five hundred dollars($500).):
C]1,as owner of the property,or my employees with wages as their sole compensation,will do D AKES ❑
the work,and the structure Is not Intentletl or offered for sale(Sec.7044,Business and Profes.
sions Code:The Contractor's License Law does not apply to an owner of property who build.or WOOD LES ❑
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,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 bulids or Improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑1 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 2 /��
permit Is Iva and /3i a��60 Seismic
❑ have and will the performance
Worker's Compensation the wokfor Insurance,as required Is I by section 3700'at s
the Labor Cod or the pedarm.nce of the work for which this permit la Issued.My Worker's
-the
tlo arenas caN r nd Policy number are: q TOtel
Carder �n' p2mhey Policy No.o '�a- PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.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 lar which this permit Is Issued,I.hall not employ
any person In any manner so as to become subject to the Workers'Compensation Lewa of Call- All roof^shall belinspected prior to any roofing material being
forni.. 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
with such provisions or this permit shallibe 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 cou ny oroinances and state laws relating to building construction,and All f covert S t0 b lIS or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against Ilabilities, -�
judgments,costs and expenses which may In any way accrue against said City In consequence NATUR -
F APPLICANT DAT
. 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY