R 6200 PERMIT R_ 6
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
2 Q'
D ✓ / �6 F RESIDENTIALLY COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
Cl9r�iQoG /��(/LLl.LP-S' vas El. If yes—I understand that a Class A
NAME roof assembly is required.
NO ❑ Initial I.C.B.O.p
ADDRESS S�p�j��,� ,�� EXISTING ROOF COVERING - -
PHONE / y b — /6 6 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
n„ / TO BE REMOVED -1[£S, TO BE RETAINED
NAME—
ADDRESSy s �'p� / n TYPE OF ROOF COVERING
CITYBZIP r[/i�� L�/T�
.,933-24 . EXISTING
PHONE Aloe- rg/
�7—�p BUILT-UP ROOF ❑
LICENSE �/SL11
NUMBER tf6ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 8(commenting with Section WOOD SHAKES
7000)01 Division 3 of the Business and Professions Code,and my license is In full force and
effect.
/r..,' Ael WOOD SHINGLES ❑
License Claes�� Lie.Number S
9; _, ,G OTHER(SPE
Date Contractor CIFY) El
OWNER-BUILDER DECLAR ION PROPOSED
I hereby affirm that I em exempt from the Contractor's License Law for the following reason.
(Sec.construct,
It Business and demolish,
or rep Code: Any city or county which requires a permit to
construct,alter.Improve,to file signed statemenair any t
Structure,is licenseor to Issuance,also eprovisions the BUILT-UP ROOF
applicant for such permit a Ale a donate 9(comm that he lith Sectio pursuant to the ofth
of the Cont nd Prof License Lew(Chapter S(commencing therefrom
Section 7000)of for the 3 of the
• of the c antl Professions Code)or that he le exempt therefrom end the heals for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e dull as
of not more than five hundred dclient($5001.):
❑I,ae owner of the property,or my employeeswith wage:as their solea eation,will do WOOD SHAKES ❑
the work,and the structure is not Intended or offered for sale(Sec.7044, see
sloes Code:
The Contractors License Lew does not apply to an owner of p e ty who b or SHINGLES ❑
Improves thereon,and who does such work himself or through his own em I e, he Pt
such Improvements are not Intended or offered for cele.If,however,the b I or Pm e
is sold within one year of completion,the owner-builder will have the bund, ming that he did
not ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed t gnonat cl.�j
the project(See.7044,Business and Professions Code:The Contractor' canes Le�tlas 1 98 IDE I.C.B.O.REPORT NO.
d
epplyloen ownerof property who builds or lmprovesthereon,and whoa to 'a
for such projects
with a contrectons)licensed pursuant to the Contractor's License Law. nnVIDE MFGR.INSTALLATION SPECS.
[II em exempt under Sea, ®�.'C.for this reason
Owner Aare~ ATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
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, Building (/ 7
permit is Is for by Section 3700 of the Labor Code,for the performance of the work for whim This C14-1 . Seismic^
permit la etea. `l Seismic 7
❑ have and will the performance
Worker's Compensation the work
for Insurance,as required by Section Worker's of
the Labor Code,for the p carrier and of the ware for which This permit le leauetl.My Worker's / y 7 7n
Compane n Insurance carrier end Policy number are: 7 - / Total L—L ,
Cerner Policy No. ��y02�_D - PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEM TION FROM WORKERS'
COMPENSATION INSURANCE N.OQ -j-0 j—
O
(This section need not be completed If the permit le for one hundred doflars($1 )or lees.)
certify that In the penormenca of the work for wtjjI this permit le issue not em toy l l
any person In any manner so as to become sub o war rs' amp Lew.df�aII- All roofs shall be inspected prior to any roofing material being
lorniaJ installed. If a roof is installed without first obtaining an
Dale / 5 Applicant inspection,I agree to remove all new materials for inspection.
ecome
subject to thICE eoWor Workers' mpelns tion proviAPPLICANT. 1,after sionls ofths eheiLabortifcate�CEx ,yolu mustuforthwlithshoudbcomply Applicant understands and will comply with all non point
_ with such provlelons or Ihls permit shall ba deemed revoked. Source regulations.
I certify that l have read this application and state that the above information is correct,I agree Oy fJf1
to comply with all city and county ordinances and stale laws relating to building construction,antl Al O C e gS ass"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for irr U/ /
:pection purposes.
(We)agree to save,Indemnity and keep harmtess the City of Cupertino epalnst liabilities,
judgments,costa and expenses which may in any way accrue against said City In cOneequance
annegrentmgonnleperm8. SIGNATURE APPLICANT DATE
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