R-6374 PERMIT
APPLICATION FOR CITY of CUPERTINO NUMBER R- 637
4
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(406)777-.3226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT.ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS -
I03� Cies �ON Dr RESIDENTIAL COMMERCIAL OTHER
OWNER'S - T HAZARDOUS FIRE AREA
/ ! YES ❑ N —I understand that a Class A
NAME - rs oof essemhty Is required.
. . NO Indlal 'I.C.B.O.R
ADDRESS D 4v ? _ • O FS T,e, Pr. EXISTING ROOF COVERING
PHONE
l 736 NUMBER OF EXISTING COVERINGS
VV
CONTRACTOR'S - /-
"�V r� TO BE REMOVED / TO BE RETAINED
NAME
ADDRESS y TE OF ROOF COVERING
CITYBZIP I�u/s�p ��Z Op/Mk �% VY YP
EXISTING
76
PHONE / UILT-UP ROOF ❑
LICENSE �� 6�
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION .
I hereby affirm that I am licensed under proviebns of Chapter B(commencing with Section D SHAKES
7000)of Dkvleen 3 of Me Business and Probeslone CoCe,and my license Is In full force and
affect.
�/ 6llY
' Ucenee Clew � 7 LkW INGLES El.Number -�(j� '
Date d U Canhactc 5"5H+t`xi QupF/r/G OTHER ( ❑
OMJEREUILDER DECLARATION PROPOSED
I heretry affirm that I em exenpt from the Contractors Ucense Law for the following reason. 8
(Sec.7031.5,Buslnsss and Professions Code: Any clty or county which requires a permlt to -
conslrucL alter,Improve,demolish,or repair any structure,prior to its mumcs,also requires Me BUILT-UP ROOF ❑
applicant for such permit to file a signed elatement that he Is licensed lel
pursuant to the provons
of the Contractor'.License Law(Chapter B(commencing with Sectlon 7000)of Dldslon 3 of Me n-.-
• Business arxd Professions Code)or that he Is exempt therefrom and Me basis for the alleged ASPHALT SHING 8661 S � u
exemption.Any Ndaten of Section 7031.5 by arty, mtlt applicant for a pesubjects the applicant to a
a cNll panalty of not mora Man five hundred dollars(S50o).):
El 1.an owrrer of the property,or my employes with wages as their sole compenumn,will cio WOOD SHAKES
the work,and the structure Is not Intended or offered for sale(Sec.70",Business and Proles-
dons Code:The Contractors Ucense Law does not appy to an owner of property who builds or WOOD SHINGLE
Imve
pros thereon,and who dome such wemployees,provided himself or through his on emploprovided that
such Improvements are not Intended or offered ler able.If,however,the building or Improvement
Is sold within one year of complouon,the owner-Wider will have Me bunlen of proNng that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,em exclueivaly contracting with licensed contractors to construct
the project(Sea.70",Business and Professions Code:The Comractore License Lew does not PROVIDE I.C.B.O.REPORT NO.
sppty to an owner of property who bunds or lmprows thereon,and who conbacls for such projects
with a commictor(s)licensed pursuant to Me Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reawn
owner Nate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I he affirm under penalty of perjury one of the following declaration: /�
have and will maintain a CerlHkute of Consent to self-Insure ler Workers Compensadon, BUlldln `
as provided ley SeNon 3700 of the Labor Code,ler the performance of the work ler which this r bp �O O g
permit Is Issued,
❑I haze and will malmaln Workers Compensation Insurance,ell required by Section 3700 of /Zr r 1 Seismic �� �^
fns Labor Code,for the performance of the work ler which Mb permit is Issued.My Workers 7/ l�
Compensation Insurance tamer and Polley number are: �1 - ` Total
Cam.LYATe 8d itis Policy No.S/I -y7-/o7a3 PERMIT AUTHORIZATION DATE
-- CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C�
(This section need not be completed It the permit le for one hundmid dol lace(5 100)or lase.)
I cortly that In the performance of the work M which this permlt is Issued,I shell not amvloy
any parson In erry manner so all to become subject to Me Workers'Compere los Law's of Calle All roofs II be inspected prlor to any roofing material being
Joints. 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,akar melding this CMfifcete d Exemption,you should become Applicant understands and will comply with all non int
sublect to Me Workers'Compe)aaten proNdona of the Labor Code,you must forthwith comply pP P Y point
with such pro flelons or MIs permit shell be doomed revoked. Source regulations. '
I certify Mat I have rand this application and state that the above Informal is correct I Agree
to comply with all clty and county ordinances and state laws relating to Wilding conaWdion,and All roof coverings to be glass"C"or better.
hereby authorize representatives of MIs dry to enter upon the ebovamentlonetl property ler In.
spade)purposes.
(Wm)agree m save.Indemnity entl keep harmless the a ai Cupertino against Ilebllftge, �u,1
juWenm,ants eM expenses which may In any way accrue against meld City In consequence -
of the granting of this permit SI SURE OF APPLICANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
ll DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:.
INSP. 'DATE INSP. - DATE r INSP, DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
`OFFICE COPY