R 6046 (2) APPLICATION FOR CITY OF CUPERTINO NUMBER R- 6046
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
LO LG �v C✓ RESIDENTIAL—_—L COMMERCIAL OTHER
OWNERS HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAMEroof assembly is required.
NO ❑ InNal I.C.B.O.II
ADDRESS nS4�w9 `'t EXISTING ROOFCOVERING
PHONE /'J — NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S /��� /
NAME 05 C-7)/ _s TO BE REMOVED TO BE RETAINED
ADDRESS �rTYPE OF ROOF COVERING
CITY&ZIP 6y� 7 rCu ids c+sa/�C�
EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER �r5-3,q-C ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 0(commencing with Sect WOOD SHAKES
7000)of Divlalon 3 of the Business end Professions Coda,and my license Is In full force end
effect / WOOD SHINGLES El
License Cless-�9 Uc.Number �s•3To
7-3/- 7000 GoS Gibs /ibk'�"4L OTHER(SPECIFY) ElDato Contractor
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Lew 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,alearaquireethe 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 0(commencing with Section 7000)of Division 3 of the ❑
Susi....and Professions Code)or that he le exempt therefrom and the basis for the alleged ASPHALT SHINGLES
• exemption.Any violation of Section 7031.5 by any sop l a ermlt subjects the applicant to
a civil penalty of not more than five hundred tlollere($
❑I,asownerofthaproperty,ormyemployeea It sasth nmpen/a on,wit o WOOD SHAKES ❑
the work,and the structure is not Intended or offered Isla usines nal Pr
slons Code:The Contractor's License Lew does not I o an owner of party It buil
improves thereon,and who does such work himself o gh his own employees.provide h WOOD SHINGLES ❑
such Improvements are not Intended or offered for a hog�@@�g�1d?ge bullgr
gy�llrr�0pprr�ove a
is sold within one year of completion,the owns'
-build III heVdl6eKurden pgrprdUDblat h d OTHER(SPECIFY) /✓�� w'�
not build or Improve for purpose of safe.). ������tt//
r]1,as owner of the property,em exclusively cont cling with licensed contractors to con
the project(Sec.7044,Business and Professions C d The Contractor's License Law do a PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or improves h It,and who contracts for such project
with a c m exempt under
a pursuant to the Contra PROVIDE MFGR.INSTALLATION SPECS.
' Q I am exempt under Sac.
Owner oats
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 Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this // ,
permit is ive and f Seismic
❑ neve and will the Performance
Worker's Compensation Insurance,as required by Section 3700 of
the Lobar Cotle,for the performance of the work for which rola permit is Isauatl.My Worker's /0. ,-,V0
Compensation
t,Inw
�s�ance carrier and Policy number are: Total /�
Carrler,tl /mac��N d�4271;cpr ✓e^Policy No,�����Q 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 lees.) ,( -s T ,meq
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 sublecl u e Workers'Compensation Laws of call. All roofs shall be inspected prior to any roofing material being
fornla. installed. If a root is installed without first obtaining an
DaleF Z-9 Sf Applicant inspection,I agree to remove all new materials for inspection.
subject theOWorkers'ComperataPLICANT. It, ti n provisions ofthelcate of rempron',Laborr Code,you mustuforthwld become
ith comply Applicant understands and will comply with all non point
with such provisions of this permit Shan 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 root coverings to be classA or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
sP ction(We)agree to max„ �_ —o
(We)agree to Save,costs and expenses
and keep harmless the City ai Cupertino against Ilabllitles, /lL��/ —For
of the granting of this permit.ea which may In any way accrue against said City in consequence SIGWL7RE 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