R 6626 (2) . OBD
PERMIT R_ 6626
APPLICATION FOR CITY OF CUPERTINO NUMBER ,
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 LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ II yes—I understand that a Class A
NAME iroof assembly is required.
LS
NO E] Iniffal- I.C.B.O.N
ADDRESS � ) EXISTING ROOF COVERING
PHONE. Z ,NUMBER OF.EXISTING COVERINGS /
CONTRACT 'S - -
TO BE REMOVED�TO BE RETAINED
NAME
ADDREss TYPE OF ROOF COVERING
CITY.a ZIPS
EXISTING
RHO
NP" r/ V� •T 71-070 7 BUILT-UP ROOF
LICENSE q
NUMBER �i! cJl ASPHALT SHINGLES ss
J T
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑
7000)of Divlalon 3 of the Business and Professions Code,and my license Is in full force and
affeac, WOOD SHINGLES ❑
Llcenee Cla e` Up.Number 5 !K3 5
Data 2r)v contractor' OTHER(SPECIFY
OWNER BUILDER DE Contractors
License
PROPOSED
1 hereby eHBuirm that 1 ani exempt from Professions the e: Any city License Lew for the following reason.
(Sac.7ct,alt Business end olish,orrep Code: Any city or county which requires also a permit to
construct,alter,Improve,to file signed
or statem structure,prior is Its Issuance,also reproves the BUILT-UP ROOF
appllcent for etch permit to ills a aptstatement that he Is Ilcanaetl pursuant to the provisions
of me Contractor's License Lew(Chapter B(commandop with Section 7000)of Division 3 of the G
• Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES 2-0 !~
exemption.Any violation at Section 7031.5 by any appllcent for a permit subjects the applicant to
e civil penalty of not more than five hundred dollars($500).): ys'
C]1.as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES 'ppi
the work,and the structure Is not Intended or offered for sale(sec.7044,Business and Profen .
sionsCode: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 Ih rough his own employees,provided that ❑
such Improvements are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year at completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) - ❑
not build or Improve for purpose of sale.).
❑I,as owner at the property,am exclusively contracting with licensed contractors to construct
the project(Sao, 044,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 contractor(a)ncensed pursuant to the Contramor'e License Lew. PROVIDE MFGR.INSTALLATION SPECS.
[JI em exempt under Sec. ,e it 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:
❑I have and will mentein a Certificate of Consent to self-insure for Worker's Compensation, // Bulldln U u
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Y /S/� / g
permit Is tsetse. /? VJV Seismic
have and will maintain Worker's Compensation Insurance,as required by Section 3700 of 1
the abor Coda,for the performance of the work for which this permit Is Issued.My Workers -
Cc pensatlon Ineurenre car er and Policy number ere: Total
Carrier .`7�+C77— ':7"—A.. Policy No. ii`� PERMIT AUTHORIZATION DATE -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the permit le for one hundred dollars($100)or lose.) D
I certify that In the performance of the work for which this permit Is Issued,I shell not employ
any person In any manner so as to become subject t the r am'Comps mion Laws of call- All roofs shall be irlyspected prior to any roofing material being
fornla. installed. If a roof is installed without first obtaining an
Data S q Appliaani inspection,I agree to remove all new materials for inspection.
NOTICE APPLICANT: ll,after making this Certllica of Exemption,you should become A hcant understands and will cam
subject to the Workers'Compensation provisions of the Le or Code,you must tortnwitn comply pp ply-with all non point
with such provisions or this permit shall be deemed revoked. source regulations.
I certify that l have read this appicailon and state that the above Information Is correct agree
to comply with all city and county ordinances and state laws relating to building construction,end All roof C$$$���erin sto be cl$ess or better.
hereby authorize representatives of title city to enter upon the above—mentioned property for In. //���
herebon uorizpurposes.r
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said Clry In consequence
of the granting of this permit. SIGNATURE 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY