R 6021 (2) PERIT
APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 6021
., INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
•,
BUILDING ADDRESS
180 DAYS FROM LAST CALLED INSPECTION,3 1 n T
� RESIDENTIALj—COMMERCIAL OTHER
OWNE
HAZARDOUS FIRE AREA
that
nd
NAME �V Z 'YC e;Lz YES ❑ If yes-1 understand that. Class A
roof assembly is and at
NO ❑ Initial I.C.B.O.#
ADDRESS / 1) 193, . I�� �r &27 GT � EXISTING ROOF COVERING
p
PHONE p 25-3 I
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S �f
L� Q U fes' TO BE REMOVED-----!—- TO BE RETAINED
NAME I� IJ b
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER - ASPHALT SHINGLES E]
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Cotle,and my license Is In full force and
effect.
WOOD SHINGLES ❑
License Claes Lic.Number
Date Contractor
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that I am exempt from the Contractor's License Law for the following reason.
IS
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 requires theBUILT-UP ROOF El
of
for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractors License Law(Chapter B(Commencing with Section 7000)of Division 3 of the
Business and Pmlessicns Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
• exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penally of not more than live hundred dollars($500).):
11b.es owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
lh w ISO
and the structure is not Intended or offered for sale(Sec.7044,Business and Proles-
alone Code:The Contractor's License Law does not apply to an owner of property who builda or 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 SPECIFY
not build or tmprove for purpose of sale.). OTHER(SPECIFY) ❑
O I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sac.7044,Business and Professions Code:The Contractors Licensor Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bul Ids or improves thereon,and who contracts for such projects
with a c m exempt unlicensedrSe pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B 8 P.O or iM1le rase
Owner Da A ATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATI
I hereby affirm under century of perjury one of the following decia �,� 7
❑I have and will maintain a Certificate of Consent to sell-insure l ker' Qygga a Building
aemitis Itl for by Section 3700 of the Labor Code,for the pertormenc he v��JQpnn al 1;199 / �,
p II Is Issued. j ---� tit
❑ novo and will maintain Worker's f the work
for Insurance,as r It Is Irby Stolon 3700's / �•/ TotalSeismic,�
the Labor Code,for the performance of the work lar which this per It le leauetl.My Worker's Total II//
Compensation Insurance cerrlar and Policy number are: .�y---_---__-_
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C. p,
(This section need not be completed If the permit Is for one hundred dollars($100)or less.) /
1 certify that In the performance of the work for which this permit Is Issued,I shell not employ /` , l
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 being
romla. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subject 2 theOAPPLICANT: If,after Worrkers'Compensation protvisions of tthleicate of Laborr Code,Exemption,
must foou rthwlithbecome
comply Applicant understands and will comply with all non point
with such provisions or this permit Shall deemed revokad. 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 erste laws relating to building construction III Of COVefI q&Oclas;Lor etter.
hereby authorize representatives r this city to anter upon the Bing to bentlon c Property
In-
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,coats and expenses which may In any way accrue against said City in consequence. I of thegranungatthispermit. SGNATURE FA ANT DATE
PRE4N&R9GT1ON:- PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BA FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY