R-6649 a..
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R" 6649
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)TT7-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN IN DAYS OF PERMIT ISSUANCE OR
' 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL' 'COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ IIyes-1 understand that a Class A
NAMEroof assernbty is required.
NO ❑ Initial I.C.B.O.#
ADDRESS /� � - _ EXISTING ROOF COVERING
PHONE — NUMBER OF EXISTING COVERINGS
CONTRACTOR'
TO BE REMOVED TO BE RETAINED
NAME —
ADDRESS J TYPE OF ROOF COVERING
CITY&ZIPJ�Gl
`I l/ l EXISTING
PHONE\TSV>'x5 AL3 —4 :3 73 BUILT-UP ROOF
LICENSE ry D
NUMBER p {-- / OU ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm Met I am licensed under pravlelons of Chapter 9(commencing with Section WOOD SHAKES . 6 1999
]000)of DMnlon 3 of the Business and Professions Code,and my license le In full force and 1
effect. J
License Cleve Uc.Number
Z a U ' WOOD SHINGLES
Date Contractor ER(SPECIFY) By ❑
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Busineee and Professions Code: Any city or county which requires a permit to y�
construct,cher,Improve,tlemalliM,or repair any structure,prior to is Lseuence,also requires the B P ROOF L// (
applicant for such permit to file a signed statement that he Is licensed pursuant to the prwielons
• of Me Contractors License Lew(Chapter 9(commencing with Section]000)of Division 3 of the ❑
Business and Profe icne Code)or Mat he U exempt therefrom anal the Inoue for he alleged ASPHA NGLES
exemption.Any yioiation of Section 7031.5 by any applicant for a permit subjects the applicant to
e tivll penalty of nor more than five hundred!dollars(50).):
C]1,u owner of the property,or my employees with wages as,their sola compensation,will do WOOD SHA ❑
Me work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profen-
MoneCode: The ContaciorsLicense Low don not apply toan"nor ofproperty who bulldeor WOOD SHINGLES
❑
Improves k thereon,arwho does such work himself or through his own employees,provided that
such Improvements as not intended or offered for sob.If,however,the sulking or Improvement
Is soio within one year of completion,the owner-builder will have Me burden of proving ma,he old OTHER (SPECIFY) ❑
not NMI or Improve for Purpose of sale.).
❑I,as owner of rho property,em exclusively contracting with licensed contractors to construct
the protect(Sea 7044,Business and Prcfe"ons Code:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who build,or Improves thereon,and who coniracta for such projects
with a contractoda)licensed pursuerttto the Comrac,ore License Law. PROVIDE MFGR.INSTALLATION SPECS.
F1 em exempt under Soc. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury we of the fotlowI g declaration.
❑1 hew and will maintain a Continue of Consent to"If-lKsure for Workers Compensation, 0% Buildin - DO
as provided for by Section 3]00 of the Labor Code,for the performance of the work for which this Q' g
permit iolssuetl. /l 9 ,3(),30 $eISf111C�'V
have and will malmon Worker's Compensation Insurance,as required by Section 3]00 0l I (JX
the r Code,for the Performance of the work for which this permit Is must.My Workers - � � O
Compenseuon Ins�u ace mrtleerr and Policy number are: Total
Carrier �� « '/ — Policy No. 571 PERMIT AUTHORIZATION DATE
--CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(This semion need not be completed If the permit le for one hundred dollen($100)or lose.) 7 ` .•.
I cardty that In Me performance of Me work for witioh MIs permit is Issued,1 shell not employ
any person In any manner so as to comme subject to the Workers'Compensation Lowe of Galk All roof.^shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Data 7 � Applicant inspection,I agree to remove all new materials for inspection.
Nan E TO s'Co :in,eller melting this Cehe Labctate of mp�u must shoudl forrMwithi>�a Applicant understands and will comply with all non point
subject to the Workers'Com ,after provisions of the Leber C e,
with such provisions or this permit Ma4se deemed revoked. Source regulations..
I cardty that l he"read Mie application and elate Mat rhe alcove Information Is correct.l agree
to comply SIM ail city and county ordinances and state laws relating to Ntoing constwoon,and All roof coverings to lobe-class"C"Or better. /
hereby authorize reprcaenta,lves of this city to enter upon the above-menikxatl property for lo- -2/ / !
hereby purposes. fff
(We)agree to save,Indemnify and keep harmless Me City of Cupertino eaelnel.11eblldn' ,�
Judgments,costs and expenses which may In any way accrue against veld City in consequence
of nee granting of this perms. SIGN RE OF PPLICANT DAA
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATEINSP. 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