R 6091 PERMIT R_ 6091
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (406)777-.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
A RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
�^' -/1 ] ,, YES ❑ Ii yes—I understand that a Class A
NAME /,I N + 1'f �Y1DL)S roof assembly Is required.
,yy� ?n,.,� NO -❑ Initial I.C.B.O.A
ADDRESS 6 �—� 'W_LU^ L�• '�/� kelli EXISTING ROOF COVERING
PHONE nT L0 " NUMBER OF EXISTING COVERINGS
COCONTRACTORS)34)1'S
OR � _
NAME lC S Q��Q)( CA TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP IliVe
EXISTING
PHONE(� ® �1_3 y BUILT-UP ROOF.
LICENSE -
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect. /^ WOOD SHINGLES ❑
License Class Llc.Number 3 35 2x10 A" -
DatS Contractor C� �ite �e C OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION — PROPOSED
I hereby affirm that I em exempt from the Contractors License Law for the allowing reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to a
construct,alter,Improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF ly�jT
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's Licence Law(Chapter a sous f ivlslon 3 01 the
Business and Protessions Cotle)or that n exempt t Oman 1 asis alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section7031.5 a appllc permit jects Ilcant to
e civil penalty of not more than five un to Ire($
01,as owner of the property,or my amp a with wages as their sole comp s n,will do WOOD SHAKES ❑
the work,and the structure is not man are I $$@@Ie(So 7044,Busin s Proles.
stone Code:The Contractor's License Lew no plus an aW'nall�Qt�ert builds or WOOD SHINGLES ❑
Improves thereon,and who does such war mself bugh hl 1 e lded that
such Improvements are not intended or off tl for sale.If,however,the building rovement
is sold within one year of completion,the o net-builder will have the burden of Or ' at he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.). p
❑1,as owner of the property,am exclus ay In with licensed contractors t construct
the project(Sec.7044,Business and Prof 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 10 the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
01 am exempt under Sec. ,B 8 P.C.for this reason
Owner APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration; [��� .•s
jiWave and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, Building 7 / G
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this yt�/ ODO
permit le �1(•J ued' �/r Seismic
EM ave and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's
Compensation Insurance carrier and Policy number are: /� Tota(/2 O
S� w
z
Carrierdl», . -6 ^ Policy No,%5ho 3JS7� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE IN
(This section need not be completed if the permit Is for one hundred dollars($100)100)or lees.)
I certify that In the performance of the work for which this permit Is Issued,I shell not employ
any person In any manner so as a 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,after making this Certificate of Exemption, ou ehoultl becoma
subject to the Workers'Compensation provisions aline Labor Code,you mu forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shalQbe deemed revoked. Source regulations.
I certify that l have read this application and state that the above Informations orrec1.1 to
to comply with all city and county ordinances and state laws relating to building co ucfion,antl Dof Coverin ass"C"or better.
hereby authorize representatives of this city to enter upon the above-mention etl pro for in-
spectlon purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against is lid
lodgments,croaIs and expenses which may In any way accrue against said Cly in consequence
• of the gma tag of this permit. . 5 0 A 1 NT DATE
PRE-INSPECTION: PLYWOOD: IN- GRESS:
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