R-6702 PERMI
APPLICATION FOR � 3 CITY OF CUPERTINO NUMBER R- 6702
v 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
RESIDENTIAL COMMERCIAL OTHER
OWNER's HAZARDOUS FIRE AREA
n u � n t', ( r a 9 YES ❑ If yes-I understand that a Class A
NAME �.}� l` GGAAJCJ J1J LL -f assembly is requireIM s tial I.C.B.O.k
' l f �.F EXISTING ROOF COVERING
ADDRESS {{ ` //
PHONE IOw (D — NUM ER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS /� ,Q t TYPE OF ROOF COVERING
CIT'&ZIP- -W,7 B 'Ina
/ 61 1 EXISTING
PHONE _-1 W�$, 3CoZ��f I-f BUILT-UP ROOF ❑
LICENSE / -7
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
]0001 of Division 3 of the Business and Professions Code,and my license is in full force and
effect' 9 WOOD SHINGLES El
License Class `� r q Llc.Number ZZ
If
Date 77`1�� `� Contractor OTHER(SPECIFY)
OWNER-BUILDER DE LARATION PROPOSED
I hereby affirm that I am exempt from 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,improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF
applicant for such permit to file a signed statement that he is licensed pursuant to the 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 five hundred dollars($500).): SHAKES OD SHA
I]I,as owner of the property,or my employees with wages as their sole compensation,will do WD ❑
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Pross-
alonsCode:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES El
thereon,and who does such work himself or through his own employees,provided that
such improvements are not intended or offered for sale.ll,however,the building or improvement
I.sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) El
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 Coast: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 contractogs)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date TION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: q a ��
I have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, Ll Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this ^/ D
permit is issued, �9 3 Seismic _L,t_
❑1 have and will maintain Workers Compensation Insurance,as required by Section 3700's JUL 2 1 n
the Labor code,for the performance of the work for which this permit is issued.My Worker's 19r1 Total ^`L•/
Compensation Insurance carrier an icy number are: x7
Carrier _ Policy No. w PERMIT AUTIII TION DATE
41 CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed it the permit Is for one hundred dollars($100)or less.)
1 certify that in the performance of the work for which this permit is issued,I shall not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of Cell- All roofs shall be inspected prior to any roofing material being
fornix. installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: if,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non Dint
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP P Y P
with such provisions or this permit shall be deemed revoked. source regulations.
I certify that I have read this application and state that the above information is correct.I agree
to comply with all city and county ordinances and stele laws relaling to building construction,and All no erebVer,JrJ/]�D—y1�'to be cllA/$'s'"O" better.
hereby authorize representatives of this city to Dolor upon the above-mentioned property for in. � I V�
ereben 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 City in consequence $IGfSATURE F 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