R 6000 (2) PERMIT R_ 6 0 0 0 .
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
BUILDING ADDRESS
180 DAYS FROM LAST CALLED INSPECTION.
J(
• 1/ [ ! rL�" /'� S�A � RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ It yes–I understand that a Class A
NAME !r✓ J r'r a.i roof assembly Is required.
_ NO ❑ Initial I.C.B.O.M
ADDRESS 97q EXISTING ROOF COVERING
PHONE 09
9 7—c)ry/ NUMBER OF EXISTING COVERINGS 21
CONTRACTOR'S
/� �J ,.n� 1
NAME (i o'L�`r��s LY/ _ `–® h�V$�'/v�+v TO BE REMOVED TO BE RETAINED
ADDRESS '•"�E n�Q�C� TYPE OF ROOF COVERING
CITY 8 ZIP/760 P' I�
C�
-p, EXISTING
PHONE //''��`,6 C �" ��7"�� BUILT-UP ROOF
LICENSENUMBER (O' U.� O J ASPHALT SHINGLES jly❑Q�(�
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 lull force and Leffect
icense
WOOD SHINGLES ❑
License Class � Lic.Number�r-�,�,, 1�,A1�,„�,V_�w� 1 D
Data b� 1' Contractor L+�'A"�S 6+�� � OTHER(SPECIFY) ❑
OWNER-the Conn DECLARATION PROPOSED
hereby affirm that I am exempt from the Contractor's License Lew for the following reason.
(Sec.7031.5, improve and Professions Code: Any city or county which requires a permit to
consapplicant
such
Improve,to file signed air statement
eny mentructure,that he prior tolls issuance,alstot he provisions
at
BUILT-UP ROOF
applicantforsuch permit to file asignedstatementthatg with
pursuant to the pro of the
• of the ss and tPrs License Professions
Lew(Chapter h(commencing with Section 7000)of Division 3 of the
Business and Professions Cotla)or that he Is exempt therefrom and the jbasisis for the applicant
to ASPHALT SHINGLES
exemption.Any violation of Section hundred
byany applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred tlollers($500).):
❑I,as investor theproperty,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
• the work,and the structure is not Intended or offered for sale(Sac.7044,Business and Freres.
.tans Code:no Contractor.License Law does not apply to an owner of property,who builds or WOOD SHINGLES
improves thereon,and who does such work himself or through his own employees,provided the R ❑
such Improvements are not intended or offered for sale.I(however,the building vi ig that lenPti V
not
is told build or
provne e for purpose
sthe ownerbuilderwill have the burden of proving that he did OTHER(SPECIFY)
❑
not build or Improve for purpose of sale.).
❑tee owner of Ne property.and Professions
Capvely e:
contracting with ntractors Licenicensed se L to��r-3.5 aryl
the project(Sec.70N,Business and Prolesalone Cotla:The Contractors License Lett'�{{ 0AXPROVIDE I.C.B.O.REPORT NO.
apply to an owner or property who builds or Improves thereon,and who contracts for suc p lects
with a contractor(s)licensed pursuant to the Contractor's License Law. I IRROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sae. ,B 8 P.C.f�xlilkeb0fln VUT C
Owner oats
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of penury one of the following declaration: C O
❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compensation, 7�( �^� 8 ( Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this O
palmic is i,have%du'd Seismic
Iend will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Cotla,br the performance of the work for which this permit Is Issued.My Worker's -
Compensation Insurance carrier and Policy number are: Total
Carrler5`'! ur YL_i:�� Policy No.lKE
' 98 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM wonS
COMPENSATION INSURANCE N.C.0 /+ n
(This section need not be completed if the permit Is for one hundred dollars($100)or lase.) �A /� .�
I certify that in the Performance of the work for which this permit Is issued,I shall not employ ((l1 N V 00
any person In any manner so as to become subject to the workers'Compensat on Laws of call- All roots shall be inspected prior to any roofing materiaf being
forma. 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 became
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked, Source regulations.
I certify that l have read this application and state that the above information Is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof verings to be class'g or better.
hereby authorize representatives of this city to enter upon the above-menlloned property br in- ` ��
apache)purposes.
(We)agree s save,expenses
and keep hay ay the City of Cupertino against ILDilltlee,
judgments,costs and expenses which may in any way accrue against said City In consequence 9�n NATURE OF APPLICANT DATE
. ql the granting al this permit `W`•
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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY