R 6242 PERMIT R_ 6 2 4 2 .
APPLICATION FOR CITY of CUPERTINO NUMBER
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 w HAZARDOUS FIRE AREA
(. (/ YES ❑ If yes-I understand that a Class A
NAME roof assembly is required.
1 NO ❑ Initial I.C.B.O.N
EXISTING ROOF COVERING
ADDRESS—
'LS
DDRESS 'y C
LS
PHONE 2- -5 3 a NUMBER OF EXISTING COVERINGS
CONTRACTOR — /�
/•%✓_Y--� TO BE REMOVED TO BE RETAINED /
NAME
ADDRESS TYPE OF ROOF COVERING
CITY&ZI
EXISTING
PHONE!`s/Q> 454" '1q1 Q•L, BUILT-UP ROOF ❑
LICENSEy6 O61J ASPHALT SHINGLES ❑
NUMBER
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 Code,and my license is In full force and
effect.
l�1- WOOD SHINGLES ❑
License Cla `� Lic.Number
1 l Z.00 OTHER(SPECIFY) ❑
Date Contractor
OWNER-BUILDER `[ATI6r4
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 Lew(Chattel B(commencing with Section]000)of Division 3 01 the
ie
Business and Professions Lade)or that he is exempt therefrom and the basis for the alleges 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).): ,WOOD SHAKES
❑1,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(Sac.7044,Business and Profes-
sionsCode: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 ev own employees,provided that
such improvements are not completion,
leb n,or offered for sale. ill however,the buien of pr or Improvement
n tsold build or I year of for purpose
s the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044.Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO. 12 2 Oat 3
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a comractons)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
ow
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, 00 BuildingA7.
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this p a �r
perms}is issued. Ili / /0# /00 / Seismic
1qL have and will maintain Worker's Compensation Insurance,as required by Section 3700 of (�`p��•�
thI Labor Code,for the performance of the work far which this permit is issued.My Workers Total /.+--
Compensation Insurance carne d Policy number are:
Lus„� -V-20 2'*S2`)
Carder Policy No. PERMIT AUT RIZATION DATE
V CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed if the permit is for one hundred dollars($100)or lass.) - 7^
I certify that In the performance of the work for which this permit Is issued, shell not employ
any person in ny manner so ae to become subject to the orkers'Compnseupn Laws of call. All roofs shat be spected prior to any roofing material being
fornia' J Q installed. If a roof is installed without first obtaining an
.Date 7 ` Applicant �-'�' inspection,I agree to remove all new materials for inspection.
NOTsubject to theOWorkers'Compeinsatii n proivisionis ofthetcAte of Labor Code,you mustufothwiitthbecome
comply Applicant understands and will Comply With all non point
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 state laws relating to building construction,and All roof Coverings to be Class"C"or better.
herebyauthorizepurp ze representatives of this city to enter upon the above-mentioned property for In- 41;
/ ��
hpaction purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities. �7
judgments,costs and expenses which may In any way accrue against said City in consequence SIGNATURE APPLICANT DATE
' -the granting o lois 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