R 6054 (2) PERMIT R_ 6054
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(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
Z z I S�6 jZAE GtiNe
RESIDENTIAL COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA
�! YES ❑ If yes—1 understand that a Class A
NAME -��1 �D L.i roof assembly is required.
,p� ���q,� NO ❑ Initial I.C.B.O.e
ADDRESS���Zf1�p4?z ��iree 0.0 Ve— EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
NAME 19/ i iO./ --
/YJ�/s'0 TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP /6s� S c�- �i,9�/ �.2- syrz
cc�� ) �/ EXISTING
PHONE ( 17x/097 Z 76�! ,BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
herobY affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professlons Code,and my license Is In lull force and
ell„` ri 3 4 WOOD SHINGLES ❑
License Clave Lie.Number
� OTHER(SPECIFY)
Dale Contractor
I hereby affirm that I am exempt from h the Contractors Licensse Law for the following reason. PROPOSED
(Seo.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,eller,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 a(commoncdn�with Section 7000)of Division 3 GI the
Business and Professions Code)or that he Is exempt,herefrom 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).): 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 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 El
thereon,and who does such work himself or through hie own employees,provided that
such Improvements are not Intended or offered for sale,If,however,the building or Improvement
Is sold within one year at completion,the owner-builder wl 11 have the burden of proving that he did OTHER(SPECIFY) El
build or Improve for purpose of Bale.).
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO. 1
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Lew, PROVIDE MFG R.INSTALLATION SPECS.
❑I em exempt under Sec, ,B a P.C.for this reason
Owner oma
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 aeibinsure for Workers Compensation. �� '-9L Building /37,
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which thls
permit Is Issued, t q O
❑I have and will maintain Worker's Compensation Insurance,as required by Seclicn 3700 0l t'a—/7 Seismic
the Labor Code,for the performance of the work for which this permit le Issued.My Worker's 'ff
Compensation Insurance carder and Policy number are:^ Total `
Carrie] �✓ ?_ ./ T41cyNo. ” ' PERMIT AUTHORIZATION DATE
CERTIFI ATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N00)o n p. Q
(This section need not be completed It ins permit la for one hundred dollars($100)or lase.) /� ( 7
I curtly that In the performance of the work for which this permit Is Issued,I shell not amptoy ^
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell. All roofs sha insp teorlorlW any ing material being
fornix' installed. If installed with irst obtaining an
Date Applicant inspection,I, re a7 ry t jails for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become O
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant UP
derstends an wl Com ith all non point
with such provisions or this permit shall be deemed revoked. Source reg laj; nS.
I candy that I have read this application and state that the above Information Is correct.I agree LrY
to comply with all city and county ordinances and state laws relating to building construction,and All roof CO r,
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spastic)purposes. �_/�
(We)agree s save,penesindemnify and keep harmless the City of Cupertino against liabilities,
judgments,costa and expenses winch may In any way accrue against said Clry Inconsequence
of the granting of this permit. S RE 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