R 6020 PERMIT R_ 6020
APPLICATION FOR CITY OF CUP.ERTINO 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
S4V_nJ ha,l L-at-4e
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
o,.� /.1\/A1 [yC�� I YES ❑ If yes-I understand that a Class A
NAME I ' " I t'v` / ' 6 1 � Y�r,- — roof assembly is required.
f NO ❑ Initial I.C.B.O.#
ADDRESS s"xcr ���—'�1 L�-(1�� EXISTING F
�S ',�" Qx 1)��
PHONE
NUMBER OF EXISTING COVERINGS
CONTRACTORS -
NAME c:f /TpTO BE REMOVED TO BE RETAINED
ADDRESS (_ p TYPE OF ROOF COVERING
CINBZIP 2 c�'� J Q� EXISTING
PHONE C= J ? BUILT-UP ROOF ❑
LICENSE
NUMBER 1 5 9 g�_ ASPHALTSHINGLES El
LICENSED CONTRACTORS DECLARATION �r---��
I hereby affirm that I am licenced under provisions of Chapter B(commencing with Section WOOD SHAKES P AiD
7000)of Division 3 of the Business and Professions Code,and my license is In full force and
effect. WOOD SHINGLES AUG �y
License Cies LIc.Number /AO / mn
• cT�®THER(SPECIFY) L Ji
Date Oamrea chy Ur 6Uf LHII U
OWNER-BION PROPOSED
hereby affirm al em exempt from the e: Any
License Law for the following reason.
(Sec.70315,Business and demolish,
or rep Code: Any dry or county which requires a permit to
construcapplicnt,orsuImprove,to file asigned staair tny ement that
prior to its Issuance,also to the
BUILT-UP ROOF ❑
applicant tr such permit a file a signed statement that ne IslicensedSectio 7000)of
the pro of the
of the Contractor's License Lew(Chapter B(commencing with Section 7000)of Division 3 of ins
• ex
Business ptio end violation of Code)or that he Is exempt therefrom and the basis for the applicant
to ASPHALT SHINGLES ❑
exemption.Any violationel Section 7031r by any applicant for a permit subjects the applicant to
e civil penalty of net more than live hundred dollars($500)J:
C]1,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 or offered for Bale(Sec.7044,Business and Proles.
sions Code:The Contractor's License Lew does not apply to an owner of property who builds or WOOD SHINGLES ❑
improve.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 6I within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) SZ) MII-
not build or improve for purpose of sale.).
❑I.as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.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 contractors)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. e 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
1 hereby affirm untler penalty of perjury one of the following declaration: J 7�
❑I have and will maintain a Certificate of Consent to self-Insure for Worker'.Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Seismic
❑ have and will the performance
Worker's Compensation the wokfor Insurance,as permit
by Section 3700 of
the Labor Code,for the pe mer ce of the work for which this permit le Issued.My Worker's
CompensaCtlo�lne�re a terrier en Ilcy number are: Total
Carrier ✓ s 91 #J C) Policy No.Q3a4,51 W -9 g PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.(] w
(This section need not be completed it the permit Is for one hundred dollars(5100)or lees.) 6 i
1 certify that in the performance of the work for which this permit Is Issued, shell not employ
any person In any manner so as to become subject to the Workers'Compareallan Laws of Cell- All roofs shall be inspected prior to any roofing material being
fornia. 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,after making this Certificate of Exemption,you should become Allcant understands and will comply
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.)agree
to comply with all city and county ordinances and state laws relating to building construction,and All-roo�cpverings to be class' or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In- '
spection purposes. -
(We)agree to save,Indemnify and keep harmless the City of Cupertino against Ileblllllea,'
judgments,coats and expenses which may In any way accrue against said Ciry4 consequence
of the granting of this permit. SIGNA RE OF APPLICANT-
PRE-INSPECTION:
PP ICAN 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