R 6066 (2) PER
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 606
6
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
UILDING ADDRESS ESS - -
l03'1 SaVlTa ve�sa� or l �j
RESIDENTIAL COMMERCIAL OTHER
OWNERS HAZARDOUS FIRE AREA
�I ��( �.r (A��( YES ❑ If yes
assemblystrequired.that ClassA
NAME
yy ..LL NO ❑- Initial I.C.B.O.q
ADDRESS EXISTING ROOF COVERING
PHONE Z �' �g tf / NUMBER OF EXISTING COVERINGS I
CONTRACTORSSn -
NAME TO BE REMOVED TO BE RETAINED
ADDRESS / /��n/ TYPE OF ROOF COVERING
CITY B ZIP�O � Q 1.�/( j/ ma(40
- ExIsTING
..
PHONEL-"/; l7 BUILT-UP ROOF ElNUMBEa (( L ASPHALT SHINGLES ❑
LICEN ED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect. - WOOD SHINGLES ❑
License]Cp C 1_1c.Number
Date Contractor
OTHER (SPECIFY) ❑
OWNER-BUILDER DECLARATION UPROPOSED
I hereby affirm that I am exempt from the Contractor's 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 IS,a 11 a OF E]
applicant for such permit to file a signed statement that he Is licensed pursuant fall visions
of she Contractor's License Law(Chapter 0(commencingwitheref Section 7000)of for of the
Business and Professions Coda)or that he Is exempt therefrom and the basis for 11ege A HA INGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the ant to
a civil penalty of not more than five hundred dollars($500).): nn II''((ss
❑I,as owner of the property,or my employees with wages es their sole compens i wfIAU`j 24 KES ❑.
the werk,and the structure Is not Intended or offered for sale(Sec.7044,Business d Profes.
alone Code:The Contractor's License Law does not apply to an owner of property buids or WOOD I GLES
Improves thereon,and who does such work himself or through his own employees, ovided that ❑
such Improvements are not Intended or offered for sale.If,however,the building or ppWWvement
Is Id within one year of completion,the owner-builder will have the burden of provi I� d ECIFY
not build or Improve for purpose of sale.). -- ) ❑
I,as owner of the properly,am exclusively contracting with licensed contractors to construct
the project(Sec.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 contraChm(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
p I am exempt under Sec. ,B 6 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 self-Insure for Worker's Compensebon, ^� G^ 1 Building /2-7
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 1/ (
permit is issued. Seismic
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit Is issued.My Workers / ')
Compensation Insurance carrier and Policy number are: Total 2y0=
Cerner Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ +�
(This section need not be completed If the permit is for one hundred dollars($100)or less.) 9 _ g ^Z
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 Cali. All roofs shall be inspected prior to any roofing material bei g
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 APPLICANT: If,alter making this Certificate of Exemption,you should become
subject to the Workers'Componsatlon provisions of the Labor Code,you must forthwith 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.)agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof covenn sto be class" "or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spectiherebon purposes,
judgments,
s,co s save,indemnify smnify and keep harmless nyycc Clry ai Cupertino against liabilities,
ence
of the gran costs and expenses which may In any way accrue against said City In consequence
of me granting of this permit. SIGNATURE OF APPLICANT DATE
f PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
G
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