R 6542 L o0 0 0002 - 3o2q
PERMIT R_ 6542 .
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRESIF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
fUILOING ADIIDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNEBZ, HAZARDOUS FIRE AREA
YES ❑ If yes. I understand that a Class A
NAME roof assembly is required.
NO ❑ Initial LC.B.O.M
ADORES - V Iw^r / EXISTING ROOF COVERING ,
PHONE �/ r $�L/ V NUMBER OF EXISTING COVERINGS 2
TO BE REMOVED TO BE RETAINED
CONTR
NAME TOR'S
ADDRESTYPE OF ROOF COVERING
CITY a zI E ISTING
PHONE moi► BUILT-UP ROOF
CENSE
NUMBER I I ASPHALT SHINGLES rt00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am Ilcensetl under provisions of Chapter S(commencing with Section WOOD SHAKES ❑
7000)of Division Sol the Busi ss end Professions Code,end m Icense is In full force and
effect.
(^' / WOOD SHINGLES El Clas "' Lic.Number
Date Contractor OTHER(SPECIFY,) /,/. 1 ❑.I
OWNER-BUILDER DECLARATION PROPOSED ICI _ IJ
I hereby affirm that I am exempt from the Contractor's License Law for the following re f D
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to I / FEB �O
construct,alter,improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF- ES
applicant for such permit to 1119 a signed statement that he is licensed pursuant to the provisions u
. of the Contractor's License Law(Chapter H(commencing with Section]000)01 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 ' .�t
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES-4------
the❑I,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(Sec.7044,Business and Profes-
sions Coda: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 his own employees,provided that Ti
such Improvements are not Intended or offered for sale.If,however,the building or Improvement /1
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(Sac.704,Business and Professions Code:The Contractors 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 contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
El I am exempt under Sec. ,B&P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
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 Worker's Compensation, r,A.�/"1 Building
as provided for by Boston 3700 of the Labor Code,for the performance of the work for which this (vt`/j`- /
pe l is Issued. O� f Seismic
I I and will maintain Worker's Compensation Insurance,as required by Section 3700 of /
the Labor Code,for the performance of the we*for which this permit Is issued.My Worker's Total / ��•
Compens tion Inaur na cacarrle�tl Policy num rare:
Carrier J�C// Ire PoucyNo. V4 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ ��
(TMZs section need not be completed if the permit Is for one hundred dollars($100)or less.) Lv
I certify that In the performance of the work for which this permit Is Issued,t shall not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of Can- All roofs shall be inspected prior to any roofing material being
forms. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO ecome
subject to the Worrkerss'Compensate proviafter sions ofthis ethe lLaborr Code,cate of Exemption,
ou must forthwithcomplyApplicant understands and will Compl mate'
ith 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 slate laws relating to building constructlon,antl All fC Brings t0 class" ` O eft
hereby authorize representatives of this city to anter upon the above memionatl property for In m
spection purposes. / t�J(
(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 ` SIGNATURE OF 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