R 6108 I
PERMIT R_ 6108
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LASTCALLED INSPECTION.
• BUILDING ADDRESS h (/,-1 ,/ (/^ / - ,//
• v e�/ N -`� RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS HAZARDOUS FIRE AREA
/ 1 S ,�Ct.-fr1� . 1 YES ❑ If yess I understand Mat. Class A
NAME CCII ��lJ nU rV roof -I understand
s required.
,niNO ,❑ Initial LC.B.O.B
ADDRESS �/J 0 4 l f�(J NO i✓ (/ho rw' '1 n. EXISTING ROOF COVERING
PHONE 6 4- NUMBER OF EXISTING COVERINGS
CONTRACTpRS�
J TO BE REMOVED TO BE RETAINED
NAME fbL i�
ADDRESS7 �f / TYPE OF ROOF COVERING
'�
CITYBZIP ( dO C
EXISTING
PHONE
PHONE V —4-1471 BUILT-UP ROOF
LICENSE
NUMBER 'D -7-7 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of DMsfon 3 of the Business and Professions Code,and my license Is in full force and
effect.
/, WOOD SHINGLES ❑
License Class Lic.Number �/
Data Contractor Q
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to ,�L,
Construct,alter,Improve.demolish,or repair any structure,prior to its issuance,also requires /BOILT-UIr ryO ❑
applicant for such permit to lila a signed statement that he is licensed pursuant to the provhad (/r`Q\-' t J
of the Contractor's license Law(Chapter g(commencing with Section]000)of Dlvislon 3 of t LMN/
•
Business and Professions Code)or that he le exempt therefrom antl the basis for the dI`g D ASPHALT SHI S'
exemption.ltyof Any oft morefSection hundr byanys($5antfore permit subjects the applicant t SE�do� io ❑
e civil penalty of not mora than five hundred tl011ers($500).): tA{}KS
❑1,as owner of the property,or my employees with wages as their solo Compensation,will tl E
the work,and the structure is not intended or offered for sets(Sec.]044,Business and Proles
slons Code:The Contractor's License Law does not apply to an owner of property who builds o WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided Ihel
such Improvements are not intended or offered for sale.It,however,the building or improvement
is sold within one year of completion,the owner-builder will have the burden of proving that he did 8 FY) ❑
not build or Improve for purpose of sale.). r
❑1,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
with a contractors)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
C]1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, BUllding
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /
22y—
per mit is issued. 070, Seismic + t✓ �
❑I have and will the performance
Workers Compensation Insurance,as required by Section 3700's I
the Labor Code,for the p are/mand of the work for which this permit is laeuetl.My Workers Total
Compensation Insurance carrier end Policy number are:
Carrier Policy No. PERMITAUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C{]
(This settlor need not be completed If the permit is for one hundred dollars($100)or lase.)
I certify that In the performance of the work for which this permit is Issued,I shalt not employ
any Person in any manner so as to became subject to the Workers'Compensation Laws of can- All roofs shall be inspected prior to any roofing material being
torrid' 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.subject to than Worrol Compensation pro.shot lvisionls of the ffLabor cate r Code,Exemption,
ou mustufo forthwith comshould m) Applicant understands and will comply with all non point
with such provisions or this permit shell be deemed revoked. y y y
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 I oofc B�dngsto "C"or Btter.horeby,authorize repreeenletives rt this city to enter upon the above-mentioned property for in-
spectlon purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,
granting of this permicosts and t.
which may 1n any way accrue against said City Inconsequence S ATURE OF APPLICANT DAT
. PRE-INSPECTION: PLYWOOD: VIN-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