R 6230 (2) PERMIT R_ 6230
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
r� 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
ao34s oaf
RESIDENTIAL X COMMERCIAL OTHER
OWNER'S OQ l/�1 L/A HAZARDOUS FIRE AREA
NAME- ta
�J l� +^tI}-� YES ❑ Iroof assembly is requireed.that ClessA NO ❑ Initial I.C.B.O.#ADORES$ EXISTING ROOF COVERING
PHONE Z NUMBER OF EXISTING COVERINGS Z'
CONTRALTO ' -
TO BE REMOVED �'— TO 8E RETAINED
NAME
ADDRESS
DDR _Q TYPE OF ROOF COVERING
CITY f1ZP \
f 7 l EXISTING
PHONE t�l Zf — 2-1a 0 BUILT-UP ROOF ❑
LICENSE 6 J 73 ? 8' 77
NUMBER ASPHALT SHINGLES J�/ .
LICENSED CONTRACTORS DECLARATION G
I hereby affirm tens em licensed
under provisions of Chapter 9(commencing with Section WOOD SHAKES
70 0)of Division 3 0/the Business end ntl Professions Code,and my license Is In full force and
effect. WOOD SHINGLES
License Claes r Lic.Number
Date Contractor
�y (, p �/ OTHER(SPECIFY)
� i (I
OWNER-BUILDER DECLAR ION PROPOSED
I hereby affirm that I am exempt from the Contractle,License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,all all any structure,prior to Its Issuance,also requires the BUILT-UP ROOF
applicant for ermh to signs s Is licensed pursuant to the provisions
of the Cancra Licsns heptar ( omm with Section 7000)of Division 3 of the
Business en r Salo o that a Is axe t t erefrom and the basis for the alleged ASPHALT SHINGLES ❑
exemption, ation of Section 7031.5 yanya nt for a permit subjects the applicant to
e civil penalt 1 t IyyrAHlany a hundred dollar $ gas): p ❑
❑Less rotten . rt in g�(�3�op�y0�fs t (Sec. rests compensation,Praise. WOOD SHAKES
the work,e: e,bucture s Li in n e tl seta(Sea owner
of Business and Proles- _ n
alone Code: a Contractor's License Law does n ly to an owner of property who provided
t orunprovWOOD SHINGLES ❑ ��fes[��•_ -
suchilesoh I and are
who doessuchor ork himseeredfr trough f,howehis own employees,or Improvement tent
such Impro a ere not Inoentletl or offered for sale If,however,the building or Improvement ,O
Is sold withI m lotion,the owner-builder Ill have the burden of proving that he did - OTHER(SPECIFY)
not build or mp
❑I,as owner of the property,em exclusivay con Ing with licensed contractors to construct
the project(Seo.7044,Business and Profeselone Code:The Contractor',License Law doe,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 conoractons)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 APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
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 Worker's Compensation, B'� Building
as provided I I for by Section 3700 of the Labor Code,for the performance of ma work for which this /� �� • tl
perms Ieieaoea. 10�G GOO Seismic ! G p
have end will maintain Worker's Compensation Insurance,as required by Section 3700 al
ten bar Code,for the performance o1 the work for which this permit is teamed.My Workoes •7 �j�
C mpen,atlon eu.reQnce car-rle7r antl PolDicy number are: Total `G
Carne r�-tis• Tw�n�- PolicyNa.133NN -4� 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 lase.)
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 worker ,pensadon Laws of Cali- All roofs shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Date 14f/;2 Appllrsno inspection,I agree to remove all new materials for inspection.
NOT CE subject to the APPLICANT:
o ke s Compensatio provimakinsions ofthis thelcate of Laborr Code,you must forthwiou itihbecome
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 state laws relating to building construction,and All roof coverings eclass"C"Or better
hereby authorize representatives of this city to enter upon the above-mentioned property for in. Ll//S/f
ep(We)agree to sol /t�Y
(We)agree s save, sees)which keep harmless way the Clry of Cupertino against liabilities, (zL/
of the grunting
cocoa and expenses which may In any way accrue against ealtl City Inconsequence
• of the granting onhis Parma. SIGNATURE OF 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