R 6216 (2) f APPLICATION FOR CITY of CUPERTINO NUMBER R- 6216
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 110 DAYS OF PERMIT ISSUANCE OR
160 DANS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
!-y/
/ ( RESIDENTIAL–,Z<—COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
VES ❑ If yes–I understand that a Class A
'NAME roof assembly is required.
NO ❑ Initial I.C.B.O.k
ADDRESS Sq,! EXISTING ROOF COVERING
PHONE / 3 / 7 NUMBER OF EXISTING COVERINGS f
CONTRACTOR' f
.NAME
,lT•d.� TO BE REMOVED I TO BE RETAINED
ADDRESS ,/ry 'O_ /� ��,1 _ D Q� TYPE OF ROOF COVERING
CITY&ZIP 77 c74irl. (�jyf w.a u cls
/ EXISTING
PHONE `� SO� 4/93 —117 3 BUILT-UP ROOF
LICENSE
NUMBER 700 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 of the Business and Professions Code,and my license Is In full force and
affect
License Class C.S9 Llc.Number Q � � 0WOOD SHINGLES
'
Date s Q9 Contracto,JL sx� C & A i OTHER(SPECIFY)
OWNER-BUIL DER DECLARATIO PROPOSED .
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.construct,
S.Business and demolish,
or rep Code: Any city or tinny which requires e permit to
applicant
otter,Improve,to file signed statement
eny mentrthat e,prior to Its Issuance,to the
the BUILT-UP ROOF
applicant for such permit a floe a signed statement that he Is licensedSection
Pursuant to the Provisions
of the ss and Contractor's License Lew)or that h(commencing with Section 7000)of for the 3 of the
Business end violation of Code)or 0311 he is exempt therefrom and the beefs for the alleged ASPHALT SHINGLES ❑
exemption.Any violation el Section 7031 by any applicant fora permit subjects the applicant to
a civil penalty of not more than live hundred dollars($500).):
- ❑I,as owner of the property,or my employees with wages as their soensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.706 Bus ne
slons Code:The Contractors License Law does not apply to an owner ip partysir OD SHINGLES ❑
Improves thereon,and who does such work himself or through his awn sea, qq het
such Improvements are not intended or offered for sale.ll,however,the it ng or dTprove nt
Is sold within one year of completion,the owner-builder will have the bu proving that he did ER(SPECIFY) ❑
not build or Improve for purpose of sale.). nr� //�$ xf p
❑o,as owner of the properly,am exclusively contracting with items Careef5Elotohatrgbt 1J
the project(Sec.7094,Business and Professions Code:The Contract License Law does not 8 OVIDE LC.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who tracts for such projects
with a conireclor(s)licensed pursuant tome Contractors License Le OV IDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,S/P.C.Mr this reason
Owner Date ATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, 00 Buildin Cf O r
as provided for of
Section 3700 o1 the Labor Coda,for the performance of the work far which In �/w
pe�rmft is Issuetl. 9'
T�have antl will maintain Worker's Compensation Insurance,as required by Section 3700 of i SBIsmic
the bar Code,for the performance of the work for which Ihle permit Is Issued.My Workers /��.< O
cddddmmmmPentagon Insurance terrier antl Polley number are: Total
Carrier s ^J�Ly—�+ poucyNo,L2-71—4g ��? - PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the permit Is for one hundred dollars($100)or leas.)
I cartiry that in the performance of me work for which this permit is Issued,1 shall not employ
any person on any manner so as to become subject to the Workers'Clmpensailon Laws of Call. All roofs shall be inspected prior to any roofing material being
foals' installed. If a roof is installed without first obtaining an
Dale 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 with all non oat
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP p y p
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.l agree
to comply with an city and county ordinances and state law.relating to building construction,and All roof COVerin be etasrbetter:
hereby authorize representatives of this city to enter upon the above-mentioned property for In. C/
spection purposes.
- (We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgmants
,coats and expenses which may in any way accrue against said City In coneaquence
oflhe granting of permit. RE4 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