R-6711 1 f.� �� PERMIT c�7 q
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 6 1 1
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 ADDRESS +�
(OZif-{ �C�.�,C dpi"^
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME hi'��� � a YES ❑ If yes (understand Ihaf. ClauA
oI s—I understand
is required.
Initial I.C.B.O,F
ADDRESS` _L � -� (m-F- 'I— ✓LBS EXISTING ROOF COVERING
PHONE \� J l f0 _ Q NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME ROOli TO BE REMOVED TO BE RETAINED
ADDRESS (j TYPE OF ROOF COVERING
CITY&ZIP _ q EXISTING
PHONE (tali C)1.0 BUILT-UP ROOFLICENSE
❑
NUMBER - -Z Z / ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Cade,and my license is in full force and
Lien' /s 2a p ZZ WOOD SHINGLES ❑
License Class Llc.Number
Data "-' Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt tram the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,u improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF
applicant for such permit to lila ah,or re statement that he is for to it tl pursuant to also
provisions
of the Contractor's License Law(Chapter 9(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 penalty of not more than live hundred dollars($500).):
C]1, SHAKES 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-
sions 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.IL 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 builds or improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
t3 am exempt under Sec. ,B&P.C.for this reason
Owner oats ICATI VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: _"o1 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 / ' C
permit is issued. JUS 2 1 19 //J ('CV Seismic �
have and will the pert Workers Compensation Insurance,as required by Section 3700's k� !JI—/ 7
the Labor Code,for the performance of the work for which this permit is issued.My Worker's S
Compensation surance carrier and Pon umber are: Total
Carder Policy No. IT AUTHO0 DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' ^,
COMPENSATION INSURANCE N.C. (` 1/\
(This section need not be completed if the permit is for one hundred colors($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 become subject to the workers'Compenaauon Laws of cah- All roofs shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
- Date Applicant inspection,1 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 PP P Y P
with such provisions or this permit shall be deemed revoked, Source regulations.
I certify that l have read this application and state that the above information is correct.I agree
to comply with all city and county ordinances antl state pews relating to building construction,and All fOOf C Ve be QIa55"C"�Of ballet.
hereby authorize representatives offthis
city to enter upon the above-mentioned property far in-
speclion 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 Cityin consequence SIGNATURE OF APPLICANT DATE
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSR DATEINSP. 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