R 6251 PERMIT R_
APPLICATION FOR CITY of CUPERTINO NUMBER 6 2 51
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 UST CALLED INSPECTION.
B7UILOING-ADDDRRESS
0J RESIDENTIAL COMMERCIAL OTHER
OWNER'S - - HAZARDOUS FIRE AREA
WI A y. .YES [-IIf yes-I understand that a Class
NAME JO
/+ f 7 1,4l 7 SU 'M1� roof assembly Is required.
- I I NO 0 Inifial I.C.B.O.H
ADDRESS (30`q (fTue C_ EXISTING ROOF COVERING
PHONE G/Zd NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAMETo r —,
. TO BE REMOVED-------ITO BE RETAINED
ADDRESS F Q� X77 TYPE OF ROOF COVERING
CITY&zip Cay• CU ,J- -.
EXISTING
PHONE g? _ SGG BUILT-UP ROOF
LICENSE K
NUMBER U ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby affirm that 1 em Business
need under Professions
lens of Chapter 8(commencing with Section and WOOD SHAKES ❑
7000)of Division 3 0l the Business entl under
provisions
Cotle,and r 9 license Is in full lone end
easel.
Z d 1 U WOOD SHINGLES ❑
License Class n _ LIc.Number
2 OTHER SPECIFY
Data I(.1�- g _Comrector t dx�,.--^ Iz✓ '��'u (SPECIFY) ❑
OWNER-the Conn DECLARA ON PROPOSED
hereby affirm Bu that em exempt from the Contractor's License Lew for the requires
a reason.
(Sec.70315,Business and demolish,
or rep Code: Any city or county which re,also e permit to
applicant,oralter,u Improve,to file signed statement
anystructure,Is licenseor to Its Issuance,to theprovirequires the BUILT-UP ROOF
applicant for each permit a flaw a signed abatement that g it licensed pursuant to the provisions
of the Contractor's License Lew(Chapter B(commencing with Section 7000)of DIVIfor the 3 0l the
•
axee otic and violation of Code)or that he Is exempt Therefrom and the Deals for the applicant
to ASPHALT SHINGLES
Ion
mption.Any f violation more
of Section hundred
by any applicant for a permit subjects the applicant to
o civil penalty al not more then five huntlretl tlollars($$00).):
E]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 sale(See.7044,Business and Proles. '
sions Code:The Contractor's License Lew 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
such Improvements are not intended or offered for sale.If,however,the building or improvement
is woad 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.).
01,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Cc e:The Contractor's rise Lew does not PROVIDE I.C.B.O. REPORT NO.
apply to an owner f property who builds or Improves there 6w1 ntoo for such projects
with a contractor(s)licensed pursuant to tf .Dalt a Icon a ow.
O l em exempt under Sec, ,B .for this reason PROVIDE MFGR. INSTALLATION SPECS.
Owner Dete APPLICATION DATE VALUATION PERMIT FEE
WORKE MPENSATIO,41%, �J
hereby affirm untler penalty e p ur orptgfyl�fo p on: /
0 a have and will maintain a Certl a of C ant to self-insure for war s ompensatlon, Building/
as provided for by Section 3700 of th bor Code,for the performance of the wo forwhichthle
permit Is Issued, OW
1 U� Seismic o
01 have and will the pert Worker' Compensation Insurance ctlon Worker's of l
the Labor Code,for the performance 1 wor a leauatl.My Worker's
Compensation Insurance terrier and II Total
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS`
COMPENSATION INSURANCE N.00
(TMs section need not be completed If the permit Is for one hundred dollars($100)or lase) 7
I 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 became subject to the Workers'Compensation Laws of Calk All roofs shall be inspected prior to an footing material being
forma. 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 Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P Y P
with such provisions or this permit shalfbe doomed revoked. Source regulations.
I certify that I have read this application and state that the above Information Is correct.I agree L
to comply with all city and county ordinances and elate laws relating to building consWction,and All roof coverings to be clas or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes. %,
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities, t
judgments,coats and expenses which may In any way accrue against said City In consequence
• of me granting of this permit. ATURE OF 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