R 6203 (2) PERMIT6203
APPLICATION FOR CITY OF CUPERTINO NUMBER R"
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-'3226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
�. BUILDING ADDRESS e-7
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2 2,Y e- S Y�' � C_�I V RESIDENTIAL COMMERCIAL OTHER-
OWNER'S
THEROWNER'S ��rl/�y�/��-�/� .&C S� HAZARDOUS FIRE AREA
NAME 1=007W/Lk 6041 I�C/ s �f/i g/ VES ❑ Ifyesassembly
s,required a Class A
_ NO ❑ Initial I:C.B.O.If
ADORESSzZ S m *t) � EXISTING ROOF COVERING
PHONE %/ 7 NUMBER OF,EXISTING Cg1lERINGS /
CONTRACTOR'S �j ^^C -V//
NAME LI &l r> -, !/~ 0,0 r-/�& TO BE REMOVED TO BE RETAINED
ADDRESS 55 a� ✓�� (� TYPE OF ROOF COVERING
CITY&ZIP. l .7 J
EXISTING
PHONE C '' lel—9�/ BUILT-UP ROOF ❑
LICENSE
NUMBER JD 47 5b//_ ASPHALT SHINGLES El LICENSED licensed under RACTORS DECLARATION /
hereby affirm that am usisunder provisions of Chapter 0(commencing with f Section WOOD SHAKES 6�iM
7000)of Division 3 0l the Business and Professions Coda,and my license Is In lull force and
affect. WOOD SHINGLES
'
License Class � •9 Up.Number ����/ ❑
Date Contractor OTHER(SPECIFY) ❑ ��
OWNER-BUILDER DECLARATION PROPOSED
I hereby afllrm
that I am exempt from the Contractor's License Lew for the following reason.
(Sec.7031.5,Business and Professions Coda: 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 E
of the Comractors License Law(Chapter 9(commencing with Section 7000)of 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 t0
a civil penalty of not more than five hundred dollars(8500).): WOOD SHAKES
❑I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure is not Intended 0r Offered for sale(Sec.7044,Business and Profes.
sions Code:The Contractor's 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 ar offered for sale,ll,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) ❑
not build or improve for purpose of sale.).
❑1,as owner of the property,am exclusovaly contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License 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 Centractor(a)licensed pursuant to the Contractors License Law. .PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: a.r
❑1have and will maintain a of the Labor
Consent toself-insure performa for of
we Compensation, Building
permit
ectins is for by Section 3700 of the Labor Cotla,for the performance of thework for which NleMy
par mit is Issued. "V Seismic
❑I have and will maithe tainPerformance
Worker's Compensation the work
Insurance,as required Is I by Section 3700 s q^)
the Labor Code,for the performance of the work for which this permit la lesuetl.My Worker's IV Total
Compensation Insurance carrier and Policy number are:
Carrier SInIkX gi 1=4 w� Policy No, PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.O] a
(This section need net be completed if the permit Is for one hundred dollars($100)or less.) � t t�LL 1L / •t.. J
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 Laws of Call. II roofs shall be Inspected p for to a0 rooting material being
fornix' 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: 11,after making this Certificate of 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 shalgbe deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information Is correct.I agree
to comply with all city and county ordinances and slate laws relating to building construction,and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentoonetl property for in.
spection purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities, '
judgments,costs 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. 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