R-6645 APPLICATION FOR CITY OF CUPERTINO
'[ PERMIT
NUMB R R- 6645
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (40B)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WI DN 180 DAYS OF ISSUANCE OR
180 DCALLED FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S �^r HAZARDOUS FIRE AREA
/ .. �Otl` YES ❑ If yes—I understand that a Class A
NAME ICA r l root assembly.mgUaZ .
NO ❑ Initial I.C.B.O.i
ADDRESS �(O� 17q/ / EXISTING ROOF COVERING
PHONE �+ / 2--Z�7 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME -
COA ICA N �I� ' TO BE REMOVED TO BE RETAINED
" F-�
ADDRESS3-31 �/ TYPE OF ROOF COVERING
CITY a zIP !+ FXISTIN
PHONE
72_111-:- 76�T BUILT-UP ROOF ❑ '
NUMBER ZI Gi S�Z ASPHALT SHINGLES ❑
UCENSED CONTRACTORS DECLARATION
I hereby aMrtn that I am licensed under provist"of Chapter 9(commendnp with SOMM WOOD SHAKES - -
7000)of Dhislon 3 of Me Business end Professions Code,and any licence a in fun force and -
Offset.
C_39 2.11652 WOOD SHINGLES
License Ga„ Uc.Number
Date Carta Mr _ OTHER(SPECIFY) ❑ _
OWNER-BUILDER DECLARATION PROPOSED
I hereby allirm Mat I f m exempt ham the Contractors Lkenee Lew for the following re -
(Sec.7031.5,Business and ProfwlDns Code: Any city or county which require,a permK
construct,alter,Improv,demolish,or repair any structure,prior to Its lssusrxxf,also require, BUILT-UP ROOF ❑
applicant for such permit to 1116 a slgned statement that he b licensed pursuant to Me proal
of the Contractor a License Law(Chapter 9(commarxinp with Section 7000)of Dlvlslon 3 • -
• Business ark Professlons Coda)or that he Is exempt iherefrcm and the Is for the allegedPH LT SHINGLES �.
exemption.Any violation of Section 7031.5 by any applicant for a permit sub lecta Me applicant to
a civil Penalty of not muse men five hundred rollers($500).):
❑1,m owner of the property,or my employees wAth wages as Mcompensation,will sole compensawin do 'WD SHAKES ❑
sire work,and the structure U not Intended or offered kxr cele(Sac.7044,Business and Pmtes-
alone Code:The Contractors License Lew does not appy to an owner of property who builds or WOOD SHINGLES
Improves thereon,ark who does such work himself or through his own employees,provided that ❑
such Improvements are rat Intended or offered for sale.11,however,the building or Improvement
Is sake within one year of completion,the ownarbulldor will have the burden of proving that he dict OTHER(SPECIFY) ❑
not Wlkl or Improve for purpose of sale.).
1,asowneroftheproperty,emexduevelycwtrochwithllcensedcontractorstoconstruct
Me project(Sac.7044,Business,and Professions Cade:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO.
appy to an owner of proporty wire builds or improver,thereon,ami who contracts for such project,
wIM a contractor(s)licensed pursuant to Me Contractors Llcenae Law.. . PROVIDE.MFGR. INSTALLATION SPECS.
I am exempt under Sec. ,B 8 P.C.for this reason
Owner cote
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following dedaratbn:
[:11 have and will maintaln a Cartillcate of Consent to self-Insure for Worker's Compensation, ,,,may / D Building
as provided for by Section 3700 of the Labor Coce,for the performance of the work for which We (/
pelmet I issued. $eISmIC O
�y'f have and will maintain Worker's Compansetlon Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit Is Issued.My Workar's
Compensation/I�ns,.0 r��nce earnIfIlcy number are: Total I
Cartier '- ` w1� Policy Ne.aas-990007lS�r PERMIT AUTHORIZATION DATE
-- CERTIFICATE OF EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE N.C.0
(Thio section need not be completed If the permit u for one hunched dollars(f 100)or Ines.)
I certity met In the performance of the work for which this permit is Is,uetl, shell rust emplq
arty pareon 1n any manner act as to become subject to the Workers'Compamauon Lew,of can- All roofs shall be inspected prior to any roofing material being
ferns. installed. If a roof is installed without first obtaining an
Data Applicant Z.AL 4.4L, inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Cerftlloete of Exemption,you ahmk became - Applicant understands and will comply with all non int
subject to Me Workers'Compensation provisions of Me Labor Code,you must fortlrwith comply pP P y PD
with such provisions,or this permit shalCbe deemed revoked. source regulations.
I cattily that I have read this applk:atbn and state Mat the above Information Is correct.I agree
to mmpty MM so dry ark county ordinances and state laws relating to bulking constnrcuon,and All roof coverings to be class"C"or better.
hereby authorize representativas of this city to enter upon the above-mentloned property for in.
spa WePurposes. ; / ` ` t•y
(We))agree tos leve,Indemnity entl keep I hermlay tits City of Cupertino y In co liabuties; (�/r",•,�i��— /G—!l
Of 9menle,mats and expenses which may In any way accrue egelnM eeW Gry In caneequama SIGNATURE OF APPLICANT DATE
Of a granting of tine permit.
• 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY