R 6261 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 6261
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• ISO DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S• HAZARDOUS FIRE AREA
.NAME— JhPf V�12 t• (✓V YES ❑ If yes—I understand that a Class A
roof assembly is required.
NO ❑ Initial I.C.B.O.# '
ADDRESS C� EXISTING ROOF COVERING
PHONE — (O('0 NUMBER OF EXISTING COVERINGS '
CONTRACTOR'S t!
NAME ?OSS 1044C S QC�QP+nC TO BE REMOVED TO BE RETAINED
CITY ADDRESS.z P �t l�['o41n QAIR s \ f 101- - TYPE OF ROOF COVERING
EXISTING
PHONE_C2�q+N!d 00 BUILT-UP ROOF ❑
LICENSE
NUMBER -' 3la6q ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter S(commencing with Section WOOD SHAKES
700 0)of Division 3 of the Business and Professions Code,and my license is In lull force and
effect. '�
License Class �' �q Lie.Number-N- L WOOD SHINGLES ❑
I I-a-gYj d p ;n OTHER(SPECIFY)
Date Contractor
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that am exempt from the Contractor's or roue Lew for the following reason. �•L'.�
(Sac.7construct,alt Business and Professions re Cotle: Any city or county which requires e
applicant for
alter,improve to file asigned statemeair any nt
t ,prior to ltel resih BUILT-UP ROOF ❑
applicant for each permit to file a signed atetament roar ha✓ at to the vision LId
of the Contractor's License Law(Chapter S(commencin Section 1 Dlvlsi n oIth
• Business and Profession.Code)or that he Ie exempt t r m an for the allege D ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any epp0ca o permit subjects the applicants
a civil penalty of not more than live hundred 11 he($50 �(]Q�
❑I,as owner of the property,or my employees with we a th99�Ir��ppl�cc �se11o�,W.4rtlo WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for a Ses% 4,Bualnas antl Profea-
slonsCode:The Contractor'.License Law does not apply n owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or thro his own employees,provided that
such Improvements are not Intended or offered for sale.It. owevel,the building or Improvement
Is sold within one year of completion,the owner-builder willvggfe bualenof r OTHER(SPECIFY) ❑
not build or Improve for purpose of.alaJ. DY
❑1,as owner of the property,am exclusively contmcting vh%" censed contractor.to construct
the project(Sec.7044,Business and Professions Code:The Contractor's 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 contestants)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
El am exempt under Sec. ,B&P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
he affirm under penalty of perjury one of the following declaration:
have end will molntaln a Certificate of Consent to sell-Insure lar Worker's Compensation, wBuilding
y
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this � IV '� /
permit Is Issued. V Seismic
I have and will maintain Workers Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit Is Issued.My Workers
,the Labor
�Inajyre�nca caTotal
rrrier antl Policy number are: �� 1
Carrier s`^`� IL 1- Policy N0(0-qd u*411PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NA.D
(This section need not be completed if the permit Is for one hundred dollars($100)or less)
I certify that In the performance of the work for which this permit ed,I shall not employ
any person In any manner so as to become aubject to the Workers* omp neanon Laws of Call. All roofs shall be inspected prior to any roofing material'being
romla. 1 5 - installed. If a roof is installed without first obtaining an
Date `� s+ Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Code.you must forthwith comply Applicant ant understands and will comply with all non point
with such provisions or this permit shallibe deemed revoked. source regulations.
I certify that I have read this application and state that the above Informetlon le correct.I agree
to comply with all city and county ordinances and stale laws relating to building construction,and All roof coverings t CIasS "Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In
spectlon purposes.
(We)ts,m to save,expenses
and keep harmless the Clry of Cupertino y Inagainstcon Ilebllence /•/MJtl'�_
lu the gran costs and expenses which may In any way accrue against said Clry In consequence
• of ma granting of this Parma, S GNATURE 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