R 6053 (2) APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R- 6053
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408)777-'3'2'28 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
��,.� It yes-I understand that a Class A
NAME 2 YES ❑ roof assembly is required.
' Oem _ 1 NO E] Initial I.C.B.O.N
ADDRESS— r V EXISTING ROOF COVERING
PHONE - NUMBER OF EXISTING COVERINGS
CONTRACTOR'S ,/y7
NAME LAe— Imo- TO BE REMOVED TO BE RETAINED
ADDREss ��lY �� TYPE OF ROOF COVERING
CITY&ZIP
l EXISTING
PHONE 9 1 3 ��'"� BUILT-UP ROOF ❑
LICENSE f�-6�
NUMBER ASPHALT SHINGLES \�
LICENSED CONTRACTORS DECLARATION
I 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
effect. _
1G` 3 '1 WOOD SHINGLES ❑
Locens less Lic.Number J
Date ( ' _q Cantle dor ���5 ' l T t^ OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
1 hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,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 with Section 7000)01 Division 3 of the
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 applicant to
a civil penalty of not more than five hundred dollars($500).8 s
❑l,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ix
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles- p
slons Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that �� 1
such improvements are not intended or offered(or sale.It,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) Iii ❑
not build or Improve for purpose of sale.). `t t
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Lew does not PROVIDE I.C.B.O.REP(OIItIT Nb.
apply to an owner of property who builds or improves thereon,and who conlraos for such projects
with a contracroga)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,S$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:
❑1 have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, Building/77.,
es provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is Issued.
-/ ) U0(� Seismic
❑ have and will the performance
Workers f the work
for Insurance,as requiredsu rd.My 3700 s V (l
.the Leber Code,for the performance of the work for which this permit is iseued.My Workers / ^J
Compensation Insurance carrier and Policy number ore: 1 oak{/ Total (` r
Cerder� 1�I'Uv1 Q__ Policy Nollat �G3_ �� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.Q
(This section need not be completed If the permit Is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit is Issued,I shell not employ 1
any person In any manner so as to become subject to the Workers'compensation laws of Cali- All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO subject to the WorrkereCANT: If,after Compensation provisions of the Labor ivisis this ticate of rCode.Exemption,you should become Applicant understands and will comply with all non point
you moat forthwith comply p y
with such provisions r this permit¢cation tleemotl revoked. SOU(C8 regulations.
1 ceto pllly that 1 have read thisapplicationordinances
and elate thatMeabove information Is correct. agree /10�
hereby authorize
rep and county of this cea and ter upon
the to building covwdioq and _ All ro erings to be class Ofd or better.
hereby authorise representatives of this city to enter upon the above-mentinnatl property for Ira
spectlon purposes. 1c qty
(We)agree to save,Indemnify and keep harmless tae City of Cupertino against liabilities,
judgments,costs and expenses which may In any way acerue against said Cityl.,CeesegaerlCe
of the granting of this permit. TURE 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