R-6642 PERMIT R_ 6
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION P M 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 INSPECTK)N.
BUILDING ADDRESS ��O I RESIDENTIAL COMMERCIAL OTHER
OWNER'S - - HAZARDOUS FIRE AREA
] YES E] It yes—I understand that a Class A
NAME v roof assembly,a required.
Q NO ❑ Iridial I.C.B.O.Y
ADDRESS ' -7 �— I �1 EXISTING ROOF COVERING
PHONE
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S - -
�„� 1�}7L! TO BE REMOVED TO BE RETAINED
NAME � P 'l I � �. FF/p
ADDRESS J Z( I TYPE OF ROOF COVERING
CITY a ZIP J F—�
EXISTING
PHONE BUILT-UP ROOF ❑
NUMBER - ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
7000)of Divisionn ffinn3 o tthe Buusinam ess am Prol�onscodeh�pry S"�w I,I�full with inane WOOD SHAKES
All _
WOOD SHINGLES ❑
Loma a Cob G Uc.Number
(0 2 A -�j W OTHER(SPECIFY) ❑
Date Contractor
Opt from-BUILDER DECLARATION PROPOSED '
hereby effinn in that I em exempt from the Contractors orLicensecoup Lew for re blowing Permit
to
• (Sec.7031.5,Business end ProfessionsOrrep Code: Any dry or county which rep also a uirmll to.
mnsApplicant
er, al such"rmlttl file a signac! taair em structure,p licenseor to issuance,also requires ihe't BUILT-UP ROOF
of the
for such permll o flaw a Calmed statement that he Is licensed pureuent to tiro provisions they
of the as an dors Unnas Lew(Chapter a Is mendnp with Senor 7000)of for Me 3 of the
examsea entl Prefesson of
or that he le exempt therefrom and the basis for Na alleged ASPHALT SHIN
exemption.Any violatione Section hur by Anyappllcent bra permll subjects the epplkenl to
e dull penalty of not more then flue huraretl dollars($boo)J:
❑l,as owner of the property,or my employees Wath wages as their Ane compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Interese or offered for sale(Sec.7044,Business and Probe-
somCode:The Contractors License Law does not Apply to an owner of property who bull or WOOD SHINGLES
Improves thereon,end who does each work hIr ll or through his awn employees,provided that El
such Improvements are not Imerked or offered for sale.it,however,the building or Improvement
Is sold within one year of completion,the owner-builder will hem the burden of prwing that he did OTHER(SPECIFY) E]not bulla or Improve for purpose of Aide.).
01,as owner of the property,am excau"ily contreding with licensed comractora to construct '
the project(Sec.7044,Business And Pretensions Con:The Contractor's Ucense Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bullae or Improves thereon,and who contracts for such projects
with a contrectogel licensed pursuant to the Contractors"nes Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 Am exempt under Sac. ,B&P.C.far this reason
Owner - Dam
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penelry of perjury one of the following declaretbn: .
❑1 hem and will maintain a Ceruficete of Consent to w114noure or Workers Compensation, BUlldln o 7
as Pr Moes for by Section 3700 of the Labor Code,far the performance of the work far which this is
g / A�
�.`r❑mit have ad.will maintain Workers Compensation Insurance,as required by Section 3700 of -3 O seismic 0
N•Lebon Cade,for the perbrmence of the work for which this permit is Issued.My Workers
Comperl Insurance,
carrer end Policy number ere: [e ) Total 1101z,_"
carder �'`751 [�L"y �) PolcyNo. 6J PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This macron need rat be completed If the penult Is for one hundred dollars($100)or Isss.) —
I certify that In the performance of the work for which thle perml bua
Isstl, shell rat mm Iry
any person In any manner so as to be a en to me Werke ompenwtlon Laws at Lull- All roofs shall be inspected prior to any roofing material being
fornix. ' '^ �q installed. if a roof is installed without first obtaining an
Date J ApPILM Inspection,I agree to remove all new materials for Inspection.
subjectNOTICE TO APPUCANT: If,after makln Ihle Certificate of Exemption,you should become Applicant understands and will comply with all non point
wisore provisions or tthe his pe mit shell be deemed revalLabor rea. Dad°'you must brtlnwnh comply source regulations.
I cerdy Met l ham reed this application And state that the above Information Is correct.I agree
to compty with all city and county ordinencw end state laws relating to building conetrucdon,and f covering be class"O"Or betier.
hereby Authorize representatiI of this city to enter upon the above-mentioned property for Ill
spectIon purposes.
(We)spree to sem,Intlmmnny and keep harmless Me Clry of CupeNno epelncl Ilenlltlss, rj o
ludpments,coots and expenses which may In any way Accrue against wld city In carneequence "SIGNATURE OF APPLICANT - � DATE
• of tM prentlnp of this permit
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: - BATTENS: - FINAL:
If DATE INSP. 'DATE INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY I -