R 6338 (2) PERMIT R_ 6338
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
IN DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS r /
ZI SSI Fl tK�SN tG� RESIDENTIAL—COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
d/I�2 / � E� YES ❑ If yes—I understand that a Class A
NAME _-,"I 9 T roof assembly is required.
NO ❑ Initial I.C.B.O.p
ADDRESS 2—I.597 F61174,AIAC EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS 31
CONTRACTOR'S TO
NAME I "s P-04',4 TO BE REMOVED X TO BE RETAINED `
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP—
EXISTING
PHONE tEd 25-z- S7'1 2- 0 - BUILT-UP ROOF ❑
LICENSE El
NUMBER p S ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect. /
WOOD SHINGLES ❑ 4j
Ucense Cuss C, 37 Lid.Number tl 7 Y a f?
Date 12-14 798 Cant rector C� — OTHER(SPECIFY) Eli OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that I am exempt from the Contractors License Law for the following reason.
IS
7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,after,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 wth Section 7000)of Division 3 of the c—✓ ELI,-
0y
Bueineas antl Profesalana CotlV)or PheT -Is,kKpm`pllTler m en�'ih0 pdata for thhe alleged ASPHALT SHINGLE$ Dw
exemption.Any violation of Sec an 7031.5 byi4n plicentl r par oda theapplicant to /—
a civil penalty of not more than ly hpndreQ9olla"500).)
❑I,ae owner of the props OtPr}g employeeawithwegee esthair ompensetlon,will do WOOD SHAKES ❑
the work,end ins structure Is n t lid��ntled or offered for safe(3ec.7 p4 usineas and Proles-
aloneCode: The Contractor's td1LflyS any e3�lyp�ppy ne o operry who builds or yyQQD SHINGLES
Improves thereon,end woo doe in,
werkhlF�eO�r tAroJpllA�w oyees,provided that ❑
such Improvamente ere nal inu� d or offered for agile.II,however,t 15 Ing or Improvement
is sold within one yearolcompldt n,the owner-builder will have iheb n 31 proving that he did OTHER(SPECIFY) Elnot build or Improve for purpasrl of sale.).
❑I,as owner of the properry(e{r7sclusivety contracting with licensed tractors to construct
the project(Sec.7044,Bushes juin e9510 cense 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 contractons)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B S P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
1 hereby aHlrm under penalty of perjury one of the following declaration:
❑ ��
1 have and will maintain a Certificate of Consent to self-Insure for _s Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this l // 2Gu g
permit is Issued. IZ -7 /9$ llI Lo
❑I have and will maintain Workers Compensation Insurance,as required by Semlon 3700 of Seisrf11C
the Labor Cotle,for the performance of the work for which this permit Is Issued,My Workers Compensation L�
Compensation Insurance carrier andPolicy number aro: Total`
Carrier SS&
Tftf^d Policy No. I`f 973GS�-98 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This Section need not be completed If the permit Is for one hundred dollars($100)or leas.) Z
I certify that In the performance of the work for which this permit is Issued,I shall not employ
any person In any manner so as to become subject to the Workers'Compensation Law$of Can- - All roofs shall be inspected prior to any roofing material being
fo`nia. n installed. If a roof is installed without first obtaining an
Datef Z 9 Applicant •� inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: II,after making this Certificate at Exemption,you should become
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 shell be deemed revoked. Source regulations.
I certify that I have read this application and state that the above information Is correct.)agree
to comply with an city and county ordinances and state laws relating to building construction,and All roof coverings to be class" rbetter.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes. (n/
(We)agree to save.Indemnity and keep harmless the City of Cupertino against Ilabilitles,
.
judgments,
grtan,costs and ting of this permit.ees which may In any way accrue against said City in consequence 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY