R-6624 PERMIT R_ 6624 ,
APPLICATION FOR CITY OF CUPERTINO NUMBER.R—
INSPECTION.DIVISION PERMIT EXPIRK5014
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.
BUILDI G ADDRESS /
r �v �aun ,'azi
RESIDENTIAL ' COMMERCIAL OTHER
OWNER'S. - HAZARDOUS FIRE AREA
VES ❑ N yes-I understand that a Class A
NAME roof asserrldy a required.
x NO ❑ Wtlal I.C.B.O.R
ADDRESS /J - EXISTING ROOF COVERING
PHONE % — NUMBER OF EXISTING COVERINGS
CONTRACTORS,
// •I - /r _ TO BE REMOVED TO BE RETAINED
NAME /C l7� _/y,�C7(_ ��
ADDRESS _ TYPE OFROOF COVERING .
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑"
LICENSED CONTRACTORS DECLARATION - -
I hereby efOrm that I em licensed under pro elons of Chapter B(commencing with Section WOOD SHAKES .
7000)o1 DMelm 3 of the Business and Prohsslons Code,and my license b In full tome and
effect �����` WOOD SHINGLES ❑
Dienes Clens�LV_1— Lk.Number -
Date contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm Met I am exempt from Me Contractors License Law for the following reason.
(Sec.7031.5,Buenas and Professions Code: Any city or county which requires,a permit to -
coneMxY.after.Incl demdbh,or repair arry sVudurs,enter to Its Issuance,also requires ae BUILT-UP ROOF ❑
epph=t for such permit to his a efgned slatwnent Mal he Is Ilcansed pursuant to the prWskre
of Me Contractors License Lew(Chapter 8(commendng wain Section 7000)of Di 3 0f Me
Business and Professlorm Codi or that he le exempt therefrom and the tents ter Oe alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any appllcent for a permit sublecto the applicant to -
e chill pansy,of not more than five hundred dollars($5DD).):
❑I,as owner of the property,or my empkyeeawith"gas as,tlwtr sots compensation,will do ,WOOD SHAKES ❑
the work,and the structure is net Intended or offered for tato(Sec.7044,Business and Prome-
Who Code:The Contractors License Lew does net appy to an owner of property who bulbs or WOOD SHINGLES El
thereon,and who does such work himself or through his own employees,provided that
such Improwmenb ars not Intended or offered for We.If,howawr,the bulkm
building or Iemnewma
Is wk within one year of completion,Me"nor-builder will hew the burden of proving that he did OTHER(SPECIFY) " ❑
not Wid or Improve for purpose of sale.). _
❑I,as,owner of the property,em exclusivey,contrectln wkh licensed contractors to construct
the project(Sea 70«,Business end Professtero Code:Tina Contractor.Ucerue Law does not PROVIDE I.C.B.O.REPORT NO.
appy to an ownar of property who bulks or improws thereon,and who contracts la,such project
with a comructor(s)licensed pursuant to the Contractors Ucenw Law. PROVIDE MFGR..INSTALLATION SPECS.
❑I em exempt under Sec. ,B&P.C.for MIs reason
ownerDate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
1 hereby affirm under penalty,of perjury ane of Me following daderstion: /
❑1 haw and win maintain a Certificate of Consent N self-Insure for Workers Compensation, Building f0
as provksc for by Section 3700 of the Labor Coce,for Me pedormance of the work for which this - /
penult le lesuatl.
❑1 hew and will maintain Workers Compensation Insurance,as,required by Section 3700 of �1�0�, SBISmIC
the Labor Cade, r Me peri lice of M�mrkfor h tlJa Peron Is leeuetl.My Workers /�
Compo atlon renFe er nd Polley - �„9 fs Total
Canlar Icy No. /�6L`�/ `�/%=cry - PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(This eectkn need not be completed 1 the permit is for one hundred dollars($100)or lees.)
1 candy that In Me performance of Me work for which this permit Is issued,I shell not employ
any parson M any manner w as,to become subject to the workers'Campenmtten laws of Cali. All roofs shall be inspected prior to any roofing material being
fomle. installed. If a root Is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APP rs'Cohn�I�,�mpe�dMns Certificate of d Me Labor Codemyyor Exemption,you
N compld ly Applicant understands and will comply with all non point
wgento Me APPUe'
with such provhlons or this permit @haft be deemed mroked. Source regulations.
I certify that I have react this application and state that the above Information Is correct.l agree
to comply with el city and county ordinances and nate tows relating to building construction,and Al Of vs, " s to be Class .better.
hereby authorize repreeenm sus of this city,to enter upon fine abme-menfloned property lar Its _ �1
spection purposes. / `J
(We)agree M sew,Indemnity,and keep harmless the City of Cuperdno apnoat Ilebllldee
ludgm ma,costo and expenses which may in any way accrue against said Clty in.nee ... GNATURE OF APPLICANT DATE
of the granting of Mb permit.
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