R 6156 (2) PERMIT R_ 615 6
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
�COMMERCIAL OTHER
RESIDENTIAL
OWNER'S - HAZARDOUS FIRE AREA
YES ❑ If as-I understand that a Class A
NAME—�_!— Y/ 0A ///7 roof assembly is required.
NO ❑ Initial W.B.O.0
ADDRESS—is EXISTING ROOF COVERING
PHONE — NUMBER OF EXISTING COVERINGS
CONTRACTO 'S x
NAME 7,2
TO BE REMOVED ' ` TO BE RETAINED
_
ADDRESS TYPE OF ROOF COVERING
CITY B ZIP ,� �/
' PHONE- BUILT-UP ROOF ❑
LICENSE
NUMBER 7 k Z ASPHALT SHINGLES �'•
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license is in full force and
attest. (/p WOOD SHINGLES ❑
License Claae3!2 Llc.Number
Data - Coniracto f
OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Lew for the following reason.
(Sac.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 la Iicgneee•p
of the Contractors License Law(Chapter g(commencing with S@fit n 7000) Ion 3 0l h
•
Business and Professions Cotle)or that he Is exempt Ihemlro the b e ane e r ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for r It sub in
oilcan
a civil penalty of not more than five hundred dollars($500)J:
❑I,as owner of the property,or em to aas with wa asa 1 el sol®®pppp((gqppeenss@@tlQQqq,,wWjjlIWWpp,� WOOD SHAKES
the work,and the structure Is rot Intended or if rd for Bele( 04gyau5q{esslanr(yrafefAy8 ❑
slops Code:The Contractors License Lew tloas not apply to an net o((plo�—pertywo Lill o WOOD SHINGLES
Improves thereon,and who does such work himself or through h wn employees,provided that ❑
such Improvements are not intended or offeretl for sale.II,howe er,me building or Improvement C
is sold within one year of completion,the own Ill will have aypfden of proving that he did OTHER(SPECIFY) � e,
not build or improve for purpose of sale.). (3Y
❑1.as owner of the property,am exclusively contracting with 8871'S5'M1IYaCfefr
the project(See.7044,Business and Professions Code:The Contractor's 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 contractors)licensed pursuant to the Contractors License Law. PROVIDE MFGR. INSTALLATION SPECS.
[II am exempt under Sec. ,B&P.C.for this reason
Owner oats
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: �_
❑I have and will maintain a Certificate of Consent to sell for Worker's Compensation,
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Building/
permit is Issued. $91SR11C
❑I have and will the pert Workersfthe work
for Insurance,as required by Section Workers
s 700 13-2-'yo� �.QO
the Labor Code,for the maintain
Workers
of Compensation work for which this as req is Issued.My 3700 f
Compensation Insurance ranter and Policy number are: Total
Carriar� 11i 164A ltw-. Policy No. fr1li 6•EPIC�• PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ T^ I/
(This section need not be completed If the permit Is for one hundred dollars($100)or lose.) r bL /, ^ `
I certify that In the performance of the work for which this permit Is Issued,I shalt not employ
any person In any manner w as to become subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected prior to any rooting material being
forma, installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE subject to the workers'Co peinaa ion making
roiv sions o ehelL born Coode Exemption,
must forthwith should
comply Applicant understands and will Comply with all non point
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.I agree
to comply with all city and county ordinances and stole laws relating to building construction,and All roof co 'nits to be class;�3r better.
hereby authorize representatives of this city to enter upon the above-mentioned property for int
spection purposes. p
(we)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costa and expenses which may In any way accrue against said Clry Inconsequence
. o1 the granting of this permit. SIGNATURE OF/CPPLIC1tNT 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