R 6045 r
PERMIT R_ 6045
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS ,
v O�"" WP�S�CLcr�e/s' 9v�1 RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class A
NAME Al NNO ❑ roof assembly Is required
Initial I.C.B.O.N
ADDRESS
G 1 ^ EXISTING ROOF COVERING
..�
PHONE -7 NUMBER OF EXISTING COVERINGS oY
CONTRA C OR'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS TYPE OF ROOFCOVERING
CITY&ZIP EXISTING
PHONE 15&7F_/48 323� / BUILT-UP ROOF ❑
NUMBER 7 SL ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION 1
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES II"Yr'I
7000)of Division 3 of the Business and Profassions Code,and my license Is in full force and
ifBOt ' / WOOD SHINGLES' ElL
License Claes Lic,Number
OTHERS ❑
Oats Contractor
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any clry or county which requires a permit to Q
construct,alter,Improve,demolish,or repair any structure,prior to Its issuance,also requires the Ufill UP IVrg9`e Elapplicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Lew(Chapter 9(commencing with Section 7000)of Division 3 of the Qc
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged 3P�lAt SHINGLES
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($500).): ODD SHAKE ❑
❑I,as owner of the property,or my employees with wages as their sole compensation,will do
the work,and the structure Is not Intended or altered for sale(Sec.7044,Business and Probes-
alone Code:The Contractor's License Lew does not apply to an owner of property who builds or INGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.II,however,the building or Improvement
Is sold within one year of completion,theowner"builder will have the burden of proving that he did OTHER (SPECIFY) ❑
not bund or improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects ��yy � �
with a contractor(s)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.Ca9�0�
❑1 am exempt under Sec. ,B$P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE '
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: 43 '7
Z]I have and will maintain a Certificate of Consent to selbinsure for Worker's Compensation, / Building I
as provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this
permit is Issued. SBISRIIC ?
❑1 have and will maintain Worker's Compensation Inaurance,as realred by Section 3700 of ^7
the Labor Code,for the performance f the work for which this permit is Issued.My Workers �90D Total
2Z�
Campeau j�onzI,n�su�r/ance carrier antl Ilcy umber re:
caul okay �/{ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) x l..J
1 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 subject to the Workore'Compensatlon taws of Call. All roofs shall be inspected prior to any roofing material being
forms. installed. If a roof is installed without first obtaining an
Data 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 I with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP comply Y P
with such provisions or this permit shalCbe deemed revoked, Source regulations.
1 certify that I have read this application and state that the above information is correctI agree
to comply with all city and county ominancee and state laws relating to building construction,and All roof a rings to be class�Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spectionpurposes.
(We)
(We)agree to save,Indemnity and keep harmless the Clry of Cupertino apeinel liabilities,
judgments,costa and expenses which may In any way accrue against said City n consequence SfGNATURE OFAPPLTCANT DATE
of the granting of this permit.
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
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