R 6010 (2) 1A§W
• PERMIT _
APPLICATION FOR CITY OF CUPERTINO NUMBER R 6 010
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 LAST CALLED INSPECTION.
BUIL/DING ADDRESS ///�� ,}/���,�
G / 7 KJ Lf. r' K RESIDENTIAL COMMERCIAL OTHER
OWNER'S` '_ HAZARDOUS FIRE AREA -
NAME 4-� a -3 y LL Ci YES EJ• roof ye
s rengd'heeld. Class A
J
/�u 1 " NO ❑ Initial I.C.B.O.N
ADDRESS 112-417 w
9 W{ [IV. EXISTING ROOF COVERING
PHONE �+ _ • 7 3 _ 7 �'+ NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
C
NAME TO BE REMOVED TO BE RETAINED
K( O l ``�-^t
ADDRESS Or TYPE OF ROOF COVERING
CITY a zIP -3 �v
19 e/S'3OW EXISTING
PHONE— �,e BUILT-UP ROOF ❑
CENSE
NUMBER -Z 3 ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 0l the Business and Professions Code,and my license le in full force and
meat. WOOD SHINGLES ❑
License Clea Lid.Number y L
Date Contractor OTHER(SPECIFY) E]OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that I am exempt from the Contractor's License Law for the follow r e
(Sec.7031.5,Business and Professions Code: Any city or county which requires arm
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions -
. of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Divlslon 3 of the
Business and Professions Code)or that he Is exempt therefrom and the baale for the alleged
exemption.Any violation of Section 7031.5 by any applicant for a permit subject the applicant t0 .ASPHALT SHINGLES
e civil penalty of not more than five hundred dollars($500f):
01,as owner of the property,or my employees wlth wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for eels(Sec.7044,Business and Profes.
alone 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 Ih rough his own employees,provided that
such Improvements are not Intended or offered for aIle.If,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve lot purpose of sale.).
[:11;as owner of the property,am exclusively contmctlna with licensed contractors to cone__t(f�uct
the project(Sec.7044,Business and Professions Code:The Contractor's License Lew Qodp.'hot PROVIDE I.C.B4O.REPORT NO.
apply to an owner of property who builds or Imp rove'thereon,and wno contractq(p_r s0ch projects
with a c m exempt)licensed pursuant to the Contractor's Llcenee Law. Fj t PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,e 8 P.C.lar Ihl--------S
Owner WORKER'S COMPENSATION DECLARATION Data APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
�1 have and will maintain a Cortlllcate of Consent to self-Insure for War fa pompeoeation' Building /2
ee rovided for by Section 3700 of the Labor Cotle,for the pedormance oft Lr lot which this
permit is issued.
/ Seismic
❑ have and will the performance
Workermanc'a Compensation the wokfor Insurance,as repulsedsu Section 3700's C
the Labor Code,for the pedormence of the work for wM1ich this permit Is issued.My Worker's / 1 .. 7 e„
Compensation Ine1rence carr er end PoI y number are: Total L�.iJ V
Carrier �7�'L/f Policy No.0 f/& PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p ^
(This section need not be completed If the permit Is for one hundred dollars($100)or lees.) 3ay 0 A — 1 p
-15
I certify that In the performance of the work for which this permit 1'Issued,I shall not employ •L•�
any person In any manner's as to become subject to the Workero'Compensation Laws of Cali. All roofs shall be inspected prior to any roofing material being
fornia, installed. If a roof is installed without first obtaining an
Date 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 comply p
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP ply with all non point
with such provisions or this permit shall be deemed revoked. source regulations.
I certify that l have road this application and state that the above Information is correct.l agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to be class or better.
hereby authorize representatives of this city to enter upon the abova-mentioned properly for In-
spectlon purpose'.
(We)agree to gave.
Indemnity and keep harmless the City of Cupertino aggainst liabilities,
jud menta,costa and expenses which may In any way accrue against said City in consequence
or tRe graOung of this Permu. SIGNATURE 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY