R 6232 (2) PERMIT R_ 6232
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(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 / ,Q LJ
ao a q_3 �iCif t t.( — f RESIDENTIAL COMMERCIAL OTHER
OWNER'SI - HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME roof assembly is required.
NO ❑ Initial I.C.B.O.If
ADDRESS ' �2 � EXISTING ROOF COVERING
PHONE q�T J — 94 3 NUMBER OF EXISTING COVERINGS ,
CONTRACT J ,
TO BE REMOVED �- TO BE RETAINED
NAME
ADDREssO "5Qiv� �7 TYPE OF ROOF COVERING
CITYaz)IP / EXISTING
PHONP��S�J�—L/7,3 — 6 3 73 BUILT-UP ROOF ❑
LICENSE 2- ASPHALT SHINGLES
NUMBER 7 ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is in full force and
Date
WOOD SHINGLES e/ ❑ .
License Clea C- U Lie.Number J/' 0 " j7�
Dale U Contractor OTHER(SPECIFY) ❑
OWNER-the Conn DECLARATION PROPOSED
I hereby affirm that em exempt from the Contractor's License Law for the requires
reason.
(Sec.7031,5,Business and Professions Code: which requires a permit to '
construct,alter,improve,demolish,or repair any urs,prior athe BUILT-UP ROOF
applicant for such permit to file a signed slateme the le lJI��er�O pursue the prows ns
of the ssContractors License Law(Chapter 8(co ngere'awite a the E 1 for in the ❑ /
exemption.
xe ptio and Professions Code)or that he ie p t lhereirom en the b for Ih ed ASPHALT SHINGLES
exemption.Any ltyof violation more
lhan five
]$31.5 bye ep Ilea t eparmlt subjects thea II tto
a dvll.penelly of not more then Ilve hundretl dol $50 T /n hi
❑1,as owner of the property,or my employe Ith wage aethae9ale at n Il do WOOD SHAKES
the work,and the structure Is not mien 9 or ed for sale(Sec.7044, u6 stn. a afes-
donsCode:The Contractors License Lawda not apply to an owner of property I sor WOOD SHINGLES ❑
Improve$thereon,and who does such work hl e��1ryl or through his own employees,pr that
such Improvements are not Intended or offers loikp If however,the building or Improv ment
Is sold within one year of completion,the owner- raving that adid OTHER (SPECIFY) ❑
not build or Improve for purpose of sale.I.
❑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
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: O
❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, O Building/
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
pe-rm}i11sissuetl' �,50 Seismic
�Lee.,vo antl will maintain Workers Compensation Insurance,as required by Section 3700 of / /
ih/r Labor Code,for the performance of the work for which this permit Is Issued.My Workers
Comportset Insu ce carrier antl Po(lhc(�nu�mb/Je�(rgto: Total
Carrieo'� Policy Na -// PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.[D ��
(This section need not be completed It the permit Is for one hundred dollars($100)or less.) /12-7
I certify that in the performance of the work for which this permit Is Issued,I shall not employ 6/
any person In any manner so as to became Subject to the Workers'Compensation Laws of Cell. All roofs shall be inspected prior to any roofing material being
fernia. installed. If a roof is installed without first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
NOT CE APPLICANTshoul
subject 1.ttheOWorrkers'Compefnsatiorn provisionmkinls ofe
the iLabor Code,cate yoof Examlu mustufo thwlthoecome comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked, Source regulations.
I orlity,that t have read this application and state that the above Information Is correct.I agree
to comply with all city and county ordinances and stale laws relating to building construction,and All roofco Ings to OIaSEd"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
ape rposee.
(WeWe))agree to ends,ments,costs and expenses
and keep harmless the Clly ai Cupertino agalnet Ilebllltlee, Q V
oltlhs granting qt ihle pe�mlLes which may In any way accrue against said City in consequence SIG ATURE OF PPLICANT DATE
iPRE-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