R-6085 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 6085
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT r - (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN IN DAYS OF PERMIT ISSUANCE OR
:• 1 W DAYS FROM LAST CALLED INSPECTION. -
BUILDING ADDRESS
0 '33 V 1 J l A— RESIDENTIAL COMMERCIAL OTHER
OWNER'S - - HAZARDOUS FIRE AREA
NAME
YES ❑ o – u .red ureda
Class
NO 1:1 .
e.o.0
ADDRESSID (o cdeTAylo{ SI. Sr�f EXISTING ROOF COVERING
PHONE �'/ L Ols
NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S 7/�� /�
NAME �f-q (l�� 1 " V-A, l..C'J TO BE REMOVED / TO BE RETAINED -
ADDRESS {'� (/ r TYPE OF ROOF COVERING
CITY&ZIP 3' SI ��i S� • J i Q� Y _---r]---_ �J
PHONE -( — ��0,//vyy p11 � QgI�tJ11�did)D F
NUM ER �� , l..J „u ASPHAL NGLES YY''•'�_
LICENSED CONTRACTORS DEC T,10N
I hereby aMnn Mel I am licensed under pnnrekns of Chapter g(commenting wit) on WOOD S ❑
7000)of DNiskn 3 of the Business and Professions Code,end my Ikerxe Is In full I ce entl
enact. ZO BY OODSHINGLES- ❑
Ucanee Claes Uc.Number �[ . .
Date �'~ ZL w
S—g� Conuact , ` YZsr/� OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby allirm Net I am exempt fmm the Contractors Uoense Law for Me lollowng reason.
(Sec.7031.5.Business and Professions Cab: Any dry or county which requires a Permit to
cwuVuct,eoer,lmpma.demolish.w repair any structure,prior to its Issuance,also requires the BUILT-UP R OP< ❑
aapkcant kr such permit to file a signed statement that he is licensed pursuant to the Pro Ions
of the Conoectors License Lew Chapter B(commencing wish Section 7000)of Dllekr thvkn 3 N the `/ ❑
Business aProfessMlns Code,or that he le exempt therefrom end Me beets e alleged ASPHALT SHINGLES ZI
• exemption.Airy vbbllon of Section 7031.5 by any applicant for a permit surpecle the applicant to
//
e clue penalty Of not mere then five hundred dollars($500).): WOOD SHAKES
01,all;owner of Me property,or my employees with wages e,their sole compansetkn,will do / ❑
the work,and the structure is not Intended w offered for We(Sec.7044,Business and Proles-
sbrroCode:The Contractors License Lew does not apply to an owner of property who bulks or WOOD SHINGLES ;004= C3t
Imprwee thereon,ark wo
wlo does such k himself or Mrough his own employees,proMtletl that
such Improvements are not Intended or offered ler safe.If,I cmmr,Me bulking w Improvement s �,�•e
y
Is sok wiMkone year of competbn,Me owner4 ilder will have time buroen of prwkg Met he did OTHER(SPECIFY)
not bulk or Improve for purpose of sate.).
I,ae owner of tha property,em excl""e y contracting wish Ticar sed contractors to comtruct
the project ISec.7044,Business and Professional Code:The Contractors uceme Lew does not PROVIDE I.C.B.O. REPORT NO.
appy to en owner of property who bulks or knWome thereon,and who contracts for such project
with a contractor(s)licensed pursuant to time Contractors Lkonse Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 6 P.C.ler this reason
- owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of Me following declaration:
❑I he"end will maintain a Certificate of Consent to self-Insure ler Workers Compensation, Building
as provider try Section 3700 o1 the Lobar Code,for the performance of the work ler whlc l Mie
d le
per Issued. 7��QOd Seismic
/���lhsave entl will maintain Workers Compensation Insurance,ee required by Section 3700 of
_tha Labor Code,for she performance of Me work ler which this permit Is salted.My Workers
Compensation Insurance center and Policy number are; Total'
came, Pricy No. 5 !�7� y 7 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.ClD
(This section need not be completed I the permit U for wme humored dollars($100)or lees.) �j
I certify Met In the performance of Me work for which this permit is Issued,I shell not employ L !/
arty person In any manner so as to become subject to the workers'Compensation Laws of Cell All roofs shall be Inspected prior to any roofing material being
form. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after meklrg this Certificate of Exemption,you should oecon,e Applicant understands and will comply with all non point
subject to Me Workers'Compamation proNelom of the Labor Code,you must"hwi h comply pP P Y P
wish such pruvlekos or MIs permit shalgbe deemed revoked. source regulations.
I certify Met I have read this application ash stab that Me above Informatkn is contact.I agree
to comply with ell dry and county ontlinancee and state issue rotating to building construction,ark All roof coV ngSI be class'C"or better. -
hereby authorlee represenbhvee of this city to enter upon the above-mentioned property ler In- p
spection pumps". - /�
(We)agree to ewe,indemnify and keep harmless Me City of Cupertino apekst Ibblllfles,
judgments,oeets and expanses which may In arty way accrue against said City In wnsequence S G URE OF APPLICANT DATE
of the granting of this permit.
• PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSP CTION: / BATTENS: FINAL: '
INSP. DATE 7 •INSP. DATE INSP.' DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY