R 6183 (2) PERMIT R_ 6183
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION - PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
•
BUILDING 1B0 DAYS FROM LAST CA D INSPECTION.
ADDRESS
�
RESIDENTIAL COMMERCIAL OTHER
OWNERS - HAZARDOUS FIRE AREA
NAME l�'12( 1 1 lag ry G YES ❑ If yes-I understand tfiat a Class A
I f -� V roof assembly is required.
NO El initial - I.C.B.O.1f
ADDRESS 1 EXISTING ROOF COVERING
PHONE C�^ *27S>} NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
NAME �/Cks-rEL O/�rz-
TO BE REMOVED__z_TO BE RETAINED
ADDRESS n /� ..� TYPE OF ROOF COVERING '
CITY&ZIP �O/
EXISTING
PHONE�SC �36 BUILT-UP ROOF - Elof
LICENSE ❑
NUMBER (7 n ASPHALT SHINGLES
LICENSEDCONTRACTORS DECLARATION
I hereby affirm that em licensed
underunder provisions of Chapter (commencing with Section WOOD SHAKES
7000)of Division 3 0l the Business and Professions Code,and my
license Is In full torte and -
effect.
License Claes C- 39 LIc.Number Z>S��J WOOD SHINGLES ❑ {O /
/O / %/LNnFL W/I2 `
Dere Contractor OTHER(S ECIFY)
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's License Law for the following reason. ����
i7
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to rL lxs^
construct,alter,improve,demolish,or repair any structure,prior to Its Issuance,also requires to BUILT-UP F JI7�J
applicant for such permit to file a signed statement that he Pa licensed pursuant to the provisions
Of the Contractor's License Law(Chapter a(commencing with Section 7000)of Division 3 of the
• Business,end Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT NG
I®S VN--/-7exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a `V/
a civil penalty of not more than five hundred dollars($500),): ,
L as owner of the property,or my employees with wages as their vole compensation,will do WOOD SHAKES
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes.
cions Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES El
thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.ll,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have to burden of proving that he did OTHER
not build or Improve for purpose of sale.). (SPECIFY) ❑
01,as owner of the property,am exclusive contracting with licensed contractors to construct
the project(Sec,7044,Business and Professions Cade:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO. 04- 997
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractor(a)licensed pursuant to the Contractors License Lew. PROVIDE MFGR. INSTALLATION SPECS.
0 1 am exempt under Sec. ,B&P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: tt c
01 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, (.7—{�`[r CABuilding .1
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this / J gY T
permit Is issued. $eISmIC V
01 have and will maintain Worker's 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 �
Compensation Insurance carrier and Policy number are: Total
Carrier Policy 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.)
I certify that In the performance of the work for which this permit Is Issued, shall not employ �f
any pereap m any manner ae as m became subject m the workers'cempenaauan Laws of cap- All roofs shall be inspected prior o any roofing material being
forms. installed. If a roof is installed without first obtaining an
Date —�9 Applicant ..��� inspection,I agree to remove all new materials for inspection.
NOTIsubject to eWorrkerTO ls'Compef,after nsatlon provisions ofthecate of Labor Code,Exemption,
mustuforthwlltlhbecome comply Applicant understands and will comply with all non point
with such provisions or this permit shalt be deemed revoked. Source regulations. -
I certify that l have read this application and state that the above Information is correct.)agree
to comply with aft city and county ordinances and state laws relating to building construction,and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spathe)purposes. o /___/ �✓I / l / -
(We)agree s save,expenses
and keep harmless cc City a against
Cupertino against liabilities,of
the gats,casts and permit. a which may In anyway accrue against sold Clry In consequence
• of the granting of 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