R 6190 (2) PERMIT
NUMBER
INSPECTION
R- 6190
APPLICATION FOR CITY OF CUPERTINO
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408)777.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL ✓ COMMERCIAL OTHER
OWNER'S . HAZARDOUS FIRE AREA
YES Of If yes-I understand that a Class A
NAM d / root assembly is required.
NO Q Initial LG.B.O.#
ADDRESS (�//CyJr) V`r / C J.. EXISTING ROOF COVERING ,
PHONEje�SVNUMBER OF EXISTING COVERINGS /
CONTRACTOR'S ^ ^�^ -
/// TO BE REMOVED-----/-TO BE RETAINED
NAME !S/Ons
ADDRESS �/i TYPE_ OF ROOF COVERING
CITY&ZIP 'l XI
STING
PHONE 7, D5�1 BUILT-UP ROOF ❑
LICENSE
NUMBER cQ2 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter 0(commencing with Section WOOD SHAKES
70001 of Division 3 of the Business and Professions Code,and my license is in full force and
effect.
3 WOOD SHINGLES ❑
License Cl-es ^ Lie.Number
Del° Contreclor
OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that I am exempt from the e: Any city License Lew for the following reason. /0
(Sec.70315,r,Improve,
and demolish,
or rep Code: Any city or county which requires a permit to
conacantalter,Improve,to file asiorrepairenynt that he prior to Its Issuance,alsorequiresproven the BUILT-UP ROOF ❑
applicant for such permit a flaw a signed r 9(commencing
that h°o licensed pursuant to the provisions
of the
of Business
in Contractor's Professions
License Lew(Chapter B(commencing twithherefrom
Section 7000)of Division 3 pl ins
ex a exemption
and violation of Code)or the.he Is exempt therefrom antl the beats for the scant to ASPHALT SHINGLES ❑
exemptlon,Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of net more than flue hundred dollars($500).);
E]1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes-
sionsCode:TheContractoraLicenseLawdoesnotapplytoanownerofpropertywhobuildsor WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.If,however,the building or improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) i
not build or Improve for purpose of sale.).
I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(See.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of properly who builds or Improves thereon,and who contracts for such projects // h
with acomeempt nderSansed pareuen''oinsContractorsuceneeLaw. PROVIDEMFGR.INSTALLATIONSPECSIs.�
❑I am exempt under See. ,B 8 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:
❑Iheve end will mein'elnaCertificete of Consent to self-Ineurw for Worker'skompeneatlan, 9/ �Q '^1 O Building44 71 0
ee provltl or by Section 3700 of the Labor Code,for the performance of oe work for which this r /Y� KJ�
permit eaued
have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Seismic
the Labor Code,for the performance of the work for which this permit is Issued.My Worker's
Compares tlQ�nflnsu(r'a'n'c�e cJ�nor and Policy number are: Q�/Qv Total «7
Ca E1r<- 1 PolicyNo.� {J(][-7� PERMIT AUTHOPWAUQW. DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This Section need not be completed If the permit Is for one hundred dollars($10()or less.) 7d e
I certify that in the performance of the work for which this permit Is Issued,I shall not employ ras� ,t
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell. All roofs Shall be Inspe aNB(1 O I t al being
Iiinstalled. If a roof i ns. �f' ning an
Data Applicant inspection,I agree to ove all new materials f pection.
NOT CE TO APPLIANT, If,after makinyou
subject o the Workers'Compensation provisionls of thelLaborr Code,cate yolu of onm st fo thwlitlhbecome comply Applicant understan Snand will comply with all on 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.l agree
to comply with eft city and county ordinances and state laws relating to building construction,and All roof coverings to be class"C"Or b r.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
hereby
purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
ludgman's,coats and expenses which may In any way accrue against said City In consequence
onhe grangngot this permit. 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY