R 6002 (2) f PERMIT R_ 60 2
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
7 RESIDENTIAL_COMMERCIAL - OTHER
OWNERS - Mn-hoHAZARDOUS FIRE AREA
NAME —c/bP. VES ❑ IfyeS=lunderstandthata ClassA
roof assembly is required.
S f NO E] Initial I.C.B.O.N
ADDRESS -' IR �)ebl4er , nV5 II1J. n P21b 7�o EXISTING ROOF COVERING
PHONE SO 3 — NUMBER OF EXISTING COVERINGS J
CONTRACTOR'S
II ^
NAME-� r TO BE REMOVED TO BE RETAINED
ADDRESS (1� �/�pf��— TYPE OF ROOF COVERING
C41�iI�2 '/�7
�QE� x 12/ .
l p / EXISTING
PHONE ` qO g/ 3 7/—'S6Sy BUILT-UP ROOF ❑
LICENSE
NUMBER :J ASPHALT SHINGLES ❑ l�/�
LIC NSED CONTRACTORS DECLARATION L
I hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES
70001 of Division 3 of the Business and Professions Code,and my license Is In full force and
effect
�yWOOD SHINGLES ❑
License Class Q' J LIC.Number
Data Contractor
$ OTHER(SPECIFY) ❑
OWNER BUILDER DECLARATION / PROPOSED 8
I hereby affirm that I em exempt from the Contractors License Lew for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to rr$
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑ g$tSU
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions ,JUS{ i] rr11�1�$l7
of the Contractor's License Law(Chapter 0(commencing with Section 7000)of Division 3 of the ILyp)
• Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the appllcant to Cr,r axU
e civil penalty of not more than five hundred dollars($500).): GI-N uj r
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES CI�r
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
sions Code:The Contractors License Lew does not apply to an owner of property who builds or WOOD SHINGLES ❑
improves thereon,and who does such work himself or through his own employees,provided that
such improvements are not Intended or offered for sale.If,however,the building or Improvement
is sold within one year of completion,the ownenbullder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed cant ractom to construct
the project(Sec.7044,Business and Professions Cotle:The Contractor's License Law does not /14 PROVIDE I.C.B.O.REPORT NO. L14- 72(3
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contracmgs)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.❑I am exempt under Sec. ,B$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:
0 have and.111 maintain a Certificate of Consent to sell-insure for Workers Compensation, _ OV Building 117,0
as provided for by Section 3700 of the Labor Code,for the performance of the work for which tale 70o J
permit�is issued. � Seismic 70
' 1 have and will maintain Worker's Compensation Insurance,as requ l red by Section 3700 of
Compensation r� �Code,
suraance for the performance
and Policy numberrarre:hoich this permit Is Issued.My Worker's Total /o- 7J
Carrier 2d: / IlcyNo. I'141 ' PERMIT AUTHORIZATION DATE
CERTIFICATE FROM WORKERS' 'l'1I
COMPENSATION INSURANCE N.c. `
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) O e /19 A 4Z)ACG 1
I certify that in the performance of the work for which this permit Is Issued, shall not employ
any person In any manner so as to became subject to the workers'Compensation Laws of Call- All roots shall be inspected prior to any roofing material being
fornix. 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 shouttl become Applicant understands and will cam
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply ply 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.l agree
to comply with all city and county ordinances and stele laws relating to building construction,and All roof coverings t be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In. e
spathe)purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against Ilebllliles,
judgments,costa and expenses which may In any way accrue against said City In consequence
of the granting of this permit. SIGNATURE OF APPLICANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATEINSP. - 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