R 6044 (2) PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 6b44 ,
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED -
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
. . 100 DAYS FROM LAST CALLED INSPECTION.
BUILDINGADDRESS
,y ��•/ /
GO AGO,;�
RESIDENTIAL COMMERCIAL OTHER
-
OWNER'S HAZARDOUS FIRE AREA
NAME /_L4 L•eX h Y I YES ❑ If yes-I understand that a ClawA
roof assembly is required.
NO ❑ Initial _ I.C.B.O.#
ADDRESS C.L VInk2. EXISTING ROOF COVERING
PHONE ' NUMBER OF EXISTING COVERINGS
CONTRA/CJJO�R'S n•
OS IS LLY'W /C� YY6I TO BE REMOVED TO BE RETAINED
NAME C.
ADDRESS t�D /1 _X /�7/j / /SS• /1 TYPE OF ROOF COVERING
CITY 8 ZIP/" C)4 /OJ(p 1/40,q EXISTING
_ 3�
PRONE BUILT-UP ROOF ❑
LICENSEG
NUMBER17
a ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION I-
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES /f°y�I
7000)of Division 3 of the Business and Professions Code,and my license is in full force and
effect. 4 5`i WOOD SHINGLES ❑
License Claes LIc.Number
Date Conirac
OTHER(SPECIFY) ❑
OWNER,BUIL Ecu PROPOSED
I hereby affirm that I am exempt from the C r to L nse for tI Mllowi son. G/
(Sec.7031.5,Business and Professions Cod e city or county which requires Ip it to
construct,alter,improve,demolish,or repair en it ctur la' I vane also u athe BUILT-UP ROOF ❑
applicant for such permit to file a signed state het tW�II en d ura.WeRJ�.Qhe ppr ions
of the Contractor's License Lew(Chapter 0(co encin®w7th S n�000yeV41vis n f the
• Business and Professions Code)or that he I ampt therefrom and the basis for aged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by y applicant for a permit subjects the I at to
a civil penalty of not more than five hundred If 11 $500).):
Ll 1,as owner of the PropeM,army ample air sole compensation, ill do WOOD SHAKES ❑
the work,and the structure Is not Intended or o rotes.
sions Cotle:The Contractofs License Lew does not apply to an owner of property who builds or WOOD SHINGLES
improves thereon,and who dose such work himself or through his own employees,Or provided that –`�
such i within one ts year
not completion,
leb n,or owned for leer. ill however,the building Or
Is sold not bull orionrye for purpose
ache ownarvbulldarwill have the buMen of proving that he did OTHER(SPECIFY)
not build or improve for purpose of sale.).
❑I,as owner of the property,am exclusively 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 contractorts)licensed pursuant to the Convectors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason
Owner
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 self-Insure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Seismic ,
G
❑1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of
the labor Code,for the performance of the work for which this permit Is issued.My Worker's QU Total 2��
the Lab tion Insurance carrier and P y work f ore'
Card a ��/C.!!/H -/Y�9l�im.ncy No. PERMIT AUTHORIZATION - DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' _
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) y� ,�'L�
I certify that In the performance of the work for which this permit Is issued,I shall not employ V
any person In any manner so as to become subject to the Workars'Compensation Laws of Cell- All roofs shall be inspected prior to any roofing material being
tocols. 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,after making this Certificate of Exemption,you should become Applicant understands and will cam
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith cora pP ply 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 cove R Sto be class° "Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property brim � _—
hereby
purposes. QO
(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 $IG E OF APPLICANT- DATE �
. of the granting of this permit.
PRE-)NSPECTION: 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