R 6276 PERMIT. R_ 6276
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(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 �� - /
OI73 gxkvd RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
n / YES K If yes—I understand that a Class A
NAME— l�� rx CJl a roof assembly is required
NO ❑ Initial I.C.B.O.q
ADDRESS —5,4"a fir EXISTING ROOF COVERING
PHONE /0 '0077-
0 NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
k��i `� /� 74/ ;V` TO BE REMOVED TO BE RETAINED
NAME s9 i�cj..G T/ �1
ADDRESS q3 6 6; r,ahz O/ :r ,V - EXISTING TYPE OF ROOF COVERING
CITY&ZIP 7 ID ,7,
PHONE Sl0 y � Jja77 - 'p BUILT-UP ROOF
LICENSE
/ ❑
NUMBER ! SS /�7 7 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 0(commencing with Section WOOD SHAKES NL
7000)of Division 3 of the Business and Professions Code,and my license Is in full force and
aat.
6, 39 •7•S'S
Li WOOD SHINGLES El Cleae Lic.Number
SOTHER(SPECIFY) ❑
Dale' Contractor
OWNER BWLDER C A + PROPOSED
hereby affirm that I am exempt from the Contractors License y whirr the requires
a reason.
(Sec.7037.5,Business and Professions Code: Any arty or county whish requires a permit to
construct,alter,Improve,demolish,or repair ny 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 T
of the Contractor's License Law(Chapter 8(commencing with Section 7000)of Division 3 of the L's
• Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES 7
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(5500).);
❑I,as,owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure is not Intended ar offered for sale(Sec.7044,Business and Profits.
slona Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES ElIraproves 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(See.7044,Business and Professions Code:The Contractor's 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 Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,S s P.C.for this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: �/�
❑I have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, a,00 BUildin 7
as provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this ��
9 WD
permit Is issued. Seismic ,
❑ have and for the performance
Workers Compensation Insurance,as required by section Worker's
7 9 D
the Labor Code,far the pedormand of the work for which this permit Is laeuetl.My Warkerb
Compensation Insurance carrier end Policy number are: Total
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATIONIf theINSURANCE 100)o
(This section need not be completed If the permit Is for one hundred dollars($100)or lose.)
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 Call. All roofs shall be inspected prior to any roofing material being
fornix. 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,atter.making this Certificate of Exemption,you should become Applicant understands and will Com
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP ply 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 Iowa relating to building construction,and All roWEA;
Ss' or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In. ,
spection purposes,(We)agree to save,Indemnity antl keep harmless,the City of Cupertino agelnet liabilities,judgments,costs and expenses which may In any way accrue against said City Inconsequenceofthegrantingofthispermit, $IGN7ITCA T DATE
• PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
1 INSP. - DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: - FINAL:
J
INSP. DATE INSP. DATE INSP. DATE
NOTE: ,OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY