R 6022 PERMIT R_ 6 2 2 .
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1 B DAYS OF PERMIT ISSUANCE OR
• - 160 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
D 2- ( 7— RESIDENTIAL COMMERCIAL - OTHER
OWNER'S HAZARDOUS FIRE AREA
�^' C K ,,,r��-� YES ❑ If yes—1 understand that a Class A ,
NAME roof assembly Is required.
NO ❑ lnigal I.C.B.O.#
ADDRESS .3 Z7 ZS - 24A/ EXISTING ROOF COVERING
PHONE S'7' 3 S"1 / NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAMEI,J'A3�5 5 A T� b� TO BE REMOVED Z� TO BE RETAINEOZ
ADDRESS �o 7 3 p-3-5 s � S ` 173 TYPE OF ROOF COVERING
CITY d ZIP
EXISTING
PHONE 7 B-� -77 Z—ID yy BUILT-UP ROOF /4--o6 VACI-ec
LICENSE
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby affirm that 1 am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES El]000)of Division 3 of the Business and Professions Coda,and my license is in lull force and
effect. ^ ' q WOOD SHINGLES ❑
License Class Numb I
Date � � Con I S °„ p OTHER (SPECIFY ❑
OWNER-BUILD ECLARATION M' R�R PROPOSED
I hereby affirm that I am exempt from the C tractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,altar,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF 114afY3
applicant for such permit to file a Signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter g(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES 2011e. �r Tc)4-t b
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES
❑1,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 Code: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
such Improvements are not intended or offered for Sale.It,however,the building or Improvement p
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) A 1 ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct �0' ��
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C. IIIW
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 Law.
E] LON I am exempt untler Sec. P.,S& C.for this reason PROVIDE MFGRGI I T Vi. $PFOB.
-INSX-1 INSTALLATION
IATION
Owner pato APPLICATION 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 self-insure for Workers Compensation, Building /27�
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /�
perm.t Is Issued. l Q^ V $elSrrllC
)�lheve and will maintain Worker's Compensation Insurance,as required by Section 3700 01 1// (
the Labor Code,for the performance of the work for which this permit Is Issued,My Workers �y nn
Compensation Insurance carrier and Policy number are: / Total 2- ,ge
Carrier�E' l IC0AJI7 Policy No./ZSS�6fJ.-9!r PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This Secllon need not be completed It the permit is for one hundred dollar'
($100)m less.)
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 become s at to the workers'Compensation Laws of call. All roofs shall be inspected prior to any roofing material being
fornia. pinstalled. If a roof is installed without first obtaining an
Date ~�o Applicant Sooz inspection,I agree to remove all new materials for inspection.
subject a the Workers'C mpefnsatl n prov on
necome
is of theLaborCode,csft,of you mustuforthwlithccomply Applicant understands and will comply 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.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All f coverings to be class or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for im ,
6pe(We)
agree to
(We)agree to save,expenses
and keep harmless the City ai Cupertino against Ilabllence
judgments,costs and expanses which may In any way accrue against said City in consequence
of the granting of this perms, 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