R 6231 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 6 2 31
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
Ce L1 RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME o roof assernlNy is required.
NO ❑ Initial I.C.B.O.#
ADDRESS �a�'t'�--• EXISTING ROOF COVERING
PHONE �"5 NUMBER OF EXISTING COVERINGS' '
CONTRA 'S /
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS _ .grg L
TYPE OF R06F COVERING
CIN 8 ZIP ��
EXISTING
FHONE 44� — BUILT-UP ROOF ❑
LICENSE ❑
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby affirm that I em Business
antler Professions
of Chapter g(commencing In with Section WOOD SHAKES
7000)of Division 3 0l the Buelneee entl Professions Code,and my license Is In full lone and
effect. WOOD SHINGLES ❑
License Cl -& + Llc.Number • O OA
d OTHER(SPECIFY) ❑
Date Contractor
OWNER-BUILDER DECLARATI PROPOSED
I hereby affirm that 1 em exempt from the Cense w for a awing reason.
(Sec.7031,5,Business and Prolessl e: A or court hich e e permit to
construct,alter,Improve,demolish,or rtiny at lon)I suen requires the BUILT-UP ROOF ❑
applicant for such permit to file a sign eme at he a Ilceneetl pursue t t e provisions
of the ss and Contractor's License Lew(Chap commenc g with Sec gpI ou b 1 Islon 3 of the
Business end violation of Cotle orth le axe I I pM1M idle a the alleged ASPHALT SHINGLES
exemption.pAny enalty
of not
more
Section 703 en en r p I sable applicant to
e civil penalty of not more then five hurt doll nage WOOD SHAKES
❑Las owner structure
IS not I my loyeaered wepee(Sec.their Bole cosiness tion,will s. ❑
the work,and the ontr cto la not Intend ores not: for sale(Sec.7044,Business no Proles-
Ilona Code:The Contractor's Llcenee L does not apply to an owns o provided
t or WOOD SHINGLES
Improves o thereon,ands are
who doessuchor k 1)kwell ort oyg or Improvement etl that ❑
such Improvements are not Intended the
o e wever,the en building of Improvement
is not to bull thinor
prove for purposetof schen rulltlerwlllhave theburden olprovingthat he did OTHER(SPECIFY) ❑
not build or Improve for purpose of eels.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew 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 to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
[21 em exempt under Sec. ,B&P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
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 Workers Compensation, �- Building as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this g
permit is Issued. /0/p&/I b' qI jO Seismic
hove and will the performance
Workers f the work
Insurance,as requiredsu Section 370001 !! ! �.D
„Co ebor Code,for the patormend al the work for which this permit is laeuatl.My Workers
Compenaetlon I eurence carrier and Polley nQumber era: C� � Total
Car ;e fx�. Policy N `� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If the permit Is for one hundred dollars($100)arises.) T
I certify that In rhe 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 Cali. All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Dare Applicant inspection,I agree to remove all new materials for inspection.
oorafter sthis
Certificate
oryluushould
subjecttthe Wkers'Compensetlon provisions ofthe LabCode, ou mstfothwlhcomply Applicant understands and will comply with all non point
with such previsions or this permit shalQbe 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 r00fC a -R St O be Cl a"Cor betted
hereby authorize representatives of this city to enter upon the above-manfloned property for in.
Ipectlon purposes.
(We)spreecosto save,Indemnify and keep harmless the City of Cupertino against liabilities, - V
judgments, to
entl expenses which may In any way accrue against said City In consequence $IG ATURE F APPLICANT
- of the granting of this permit. ATE
• 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