R-6629 PERMIT R_ 6 6 2 9
APPLICATION FOR CITY OF cUPEI NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 - PERMIT EXPIRES IF WORK IS NOT STARTED
• WITHIN 160 DAYS OF PERMIT ISSUANCE OR -
• 160 DAYS FROM LAST CALLED INSPECTION.,
BUILDING ADDRESS `
� V`)
RESIDENTIAL COMMERCIAI OTHER
_ OWNER'S - HAZARDOUS FIRE AR
-
'T�1C F ('� -V 1 • (t,1 YES ❑ H yes—I untlerstantl that a Class A
NAME �J 1 'W— Tool assembly is required.
O ` 1 NO ❑ Initial I.C.B.O.I
ADDRESS l�>- Q-� y EXISTING ROOF COVERING
L_+
PHONE 2.1 ( Y L4 O NUMBER OF EXISTINGCOVERINGS
CONTRACTORq c (,�
NAME o N �-+-' �I7— • \ :TO BE REMOVED 2 TO BE RETAINED
�R TYPE OF ROOF COVERING
ADDRESS G'-2O" �v MFF 1p Sw. Z"
CITY 8 ZIP" 7 SIV` ` aRRI Vy .
. EXISTING
PHONE oma J 3S BUILT-UP ROOF ❑
DCENSE �1 ,
NUMBER - - - ASPHALT SHINGLES
LICENSED CONTRACTORS DECUBATION - -
I hereby affirm met I em licensed under provisions of Chapter a(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license is In full force end
excel' LOD WOOD SHINGLES ❑
Lcoase Cleve Uo Number
Dale I� I Connector OTHER(SPECIFY) ❑
OWNER-BUILDER D CLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's Doenaa Ler for the fallowing reason.
(Sec.7031.5,Business and Prolessims Code: Any dry or county which requires a permit to 1<
cosi after,improve.demoash,or repair any structure,prior to its Issuance,also requires Me - BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he is licensed pursuant to the pmvd8l"
40, of the Con ractofe Ucanea Law(Chapter B(commendng with Section 7000)of Division 3 of the
&mess and Professions Code or that he Is exempt therefrom and me basis for the alleged ASPHALT SHINGLES
exemption.Any violetlon of SeNon 7031.5 by any eppiioent for a permit euolects the applcant to
a cM)penalty of not more then five hundred dollars($501
❑I,as owner of Me property,or my employees with wages as Nair sole compensation,w'0 do WOOD SHAKES ❑
the work,and the stwomre is not Intended or offered far sale(Sec.7041,Business and Proles -
sons Code: The Contractors License Lew does not apply to an owner of property who Iwilde or WOOD SHINGLES -
Improves thereon,and who does such work himself or through his own empioyeas,provided that ❑
such Improvements are not Intended or offered for safe.11,however,Me building or Improvement -
issaidwithinoneyearofcompletion,the owner-0ullderwill he"the burden ofproving Met hedid OTHER(SPECIFY) ❑
not build or improve for purpose of sale.).
❑I,aff owner of the Property,em exclusively caroac6ng with licensed contractors to construct
the project(Sm.7044,Bunions and Professions Coda:The Contractors Ucenae Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves maroon,and who contracts for such projects
with a contrector(e)llcall pursuant to to Contractors Uwnes Lew. PROVIDE MFGR.INSTALLATION SPECS.
El em exempt under Sac. ,B A P.C.for this reason
owner Data APPLICATION DATE VALUATION PERMIT FEE
. WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certllfoate of Consent to eeff-Ineure for Workers Compensation, Building as provided for by Section 3700 of the Labor Code,for the performance of the work for which this p/, ESO,QQ
permit is all 4 I I 1 9' / Seismic yt So
❑ have and all the performance
Workers f the work
Insurance,as required by o.My 3700 s �/ r�
the Lobar Code,for the performance of the work for which Nle permit b bsued.My WaMeh
-the
Insurance carder and Polley number are Total
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
section
(This section fair n need not be completed If Ne permit r one hundred dollen($1 g0)or lose.)
I certify that In the performance of Me work lar which this permit Is blued.I then notamW q
any person In arty manner so as to becoma eu the Workers' m ensatlon Laws of Call. All roofs shall be inspected prior to any roofing material being
forms. installed. If a roof is installed without first obtaining an
Date Appnwd inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making ml Certificate of Exemptlon,yo aloula become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Coda,you must forthwith comply PP P Y
with such provolone or He poral shelObe doomed revoked. Source'regulations.
I certify Net I he"reed Nle application and state Met the above information le coned.I agree
to comply MM all city and county ordinances and State laws releting to bulfokq canatruction,end ' All roof coyBrings to be class 4ar better.
hereby authorize represenletivee of this city to enter upon the above-memfoned property for In. -
spectkan purposes.
(We)agree to save,Indemnity and keep harmless Me City of Cupertino ape Into Hebilides,
Judgments,costa and expenses which may In any way accrue against said City In consequence
• pf me grenung of this permit. SIG ATURE OF APPLICANT E
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