R 6008 (2) s
PERMIT R_ 6008
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
. WITHIN 160 DAYS OF PERMIT ISSUANCE OR
BUILDING `` 180 DAYS FROM LAST CALLED INSPECTION.
7,syADD/REBS
0, OLT2 cn/ �"/$ • RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME $ /r'�'N� bJ��ZrQ YES ❑ I�1rise by is required
r to ClassA
NO ❑ Initial I.C.B.O.#
ADDRESS— 7J 5P EXISTING�• EXISTING ROOF COVERING
PHONE �"'a ��3 YT �b NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S I
NAME
— 4 f- ipa A.,4 TO BE REMOVED / TO BE RETAINED -ADRBZP '/oA
� 4, TYPE OF ROOF COVERING
CITY I
1EXISTING
PHONE ��4 ) 4Z —y9QU BUILT-UP ROOF ❑
CENSE
NUMBER 7-7 JJ17 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Dlvlslon 3 of the Business and Professions Code,and my license is In full force and
enact. WOOD SHINGLES ❑
License Cleas " LIc.Number �� J g��—
Date ilr-'W' F c y Contractor �OJ GI OTHER(SPECIFY) ❑
__30 OWNER-BUILDER DECLARATION PROPOSED
I 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 Lew(Chapter 6(commencing with Section 7000)of Division 3 0l 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 do am($500),): #+.
01,as owner of theproperty,or my employees with wages as their Sale compensation,will do WOOD SHAKES,1 L1 l•' ❑
the work,end the structure Is not Intended or offered for sale(Sec.7044,Business and Proles- Y W
sions Cotle:The Contractors License Law does elf apply to or
his
a property who ro,lde that WOOD SHINGLES
A�StD
Improves thereon,and who does n such work effort or throuoh his own employees,provided that ❑
such Improvements
ars not intended oro neretltarsale.If,ill however,the building oiImprovement G L
not
Is told build or
prove for purpose of
owner-builderwill have the burden of proving that he dltl OTHER SP
not build or Improve for purpose of sale.). ( ) L7
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct I psJ �
the protest(See.7044,Business and Profession Code:The Contractor's License Law does not PROVIDE I�kiBAPREPbNT NO. Dp T
apply to an owner of property no builds or Improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec, ,B$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 sure for
Wo _
❑ have and will maintain a Certificate Of Consent to Performa for Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which lMe � g
perm tiS lesuetl. / L3
have end will maintain Worker's Compensation Insurance,as required by Section 3700 of (/ ,J Seismic LSV
m L bor Code,for the performance of the work for which this permit Is Issued,My Worker's
Compensation Insurance carrier and Poo/licy number are: � Total O V
Carrier A. Policy N°.•fes 7p 5'`'q PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NCO
• (This section need not be completed II the permit is for one hundred tlollare($100)or less.) �O D �� 12_
I certify that In the performance of the work for which this permit Is Issued,11shall not employ lVJ rl
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
farnia. 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: It,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Cotle,you must forthwith comply pP p y p
with such provisions or this permit shall be deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information is correct,l agree
to comply with all city and county ordinances and state laws relating to building construction.and A rings 0b Cl r.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, 7
jutlgments,costs and expenses which may In any way eccme epelnet said City In cnnsaquence
• of granting onhis permit. SIGNATUR�OF AID CANT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY