R-6104•
f
!" PERMrr R_ 610 4
APPLICATION FOR CITY OF CUPERTINO NUMBER ..
REROOF.PERMIT INSPECTION DIVISION PERMIT EXPIRA N
(408) 777.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
' WITHIN 1W DAYS OF PERMIT ISSUANCE OR
' 10 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
PRESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
_
YES ❑ R yes — I understaM that a Class A
NAME r�
mot assembly is requced.
O Itilial I.C.B.O. Y
'
D
EXISTING ROOF COVERING
ADDRESS
>
PHONEr
NUMBER OF EXISTING COVERINGS
CONTRALTO '.
'
TO BE REMOVED ___4y_i=:5_ TO BE RETAINED
NAME
ADDRESS P/
TYPE OF ROOF COVERING
CTFY a ZIP
-
EXISTING'
PHONE
BUILT-UP ROOF ❑
LICENSE
NUMBER
ASPHALT SHINGLES O
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am flceneed antler provisions of Chapter S (commencing with Section
WOOD SHAKES ❑ '
7000) of Division 3 of the Business and!Professions Code, and my license Is In full force entl
el
WOODSHINGLES • XLicense
Clave Uc. Number
OTHER (SPECIFY) El
Date convector
. OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
PROPOSED
(Sec. 7031.5, Business entl Professions Cade: Any city or county, which requires a permit to
construct, alter, Improve, demolish, or repelr any structure, prior to its issuance, elan requlres the
ILT-UP ROOF E]appllcont
for such permt to Ne a signed statement that he is licensed pursuant to the provisions
-
m Me Contractors Ucenea Law (Chapter a (commencing with Section 7000) of Division 3 of the
.�
Business entl Professions Code) or that he is exempt therefrom and the basis for the alleged
S T SHINGLES
exemption. Any Any violation, of Section 7031.5 by any applicant for a permit subjects the applicant to
'
e clivi penalty of not more than live huntlred dollars ($500).):
,•�,
OD SHAKES
❑1, ae owner of the property, or my employees wbh"gas as their sole compensation, will W
.�L' ❑
the w . end Ne structure Ie not intended or offered for safe (Sao 7004. Bualness and Profee-
alone Code: The Contractor's Ucense Lew con not simply to an owner of property who bullce ot
✓/
D HINGLES
mproves thereon, entlwho does such work himself or through hie awn employees, provdad thatsuch
tE.V9IIPECIFY)
Improvements are not Intended or offered for sale. It, however, the bulkfirg or Improvement
Is sold within one year of completion, the owner -Wilder will have the burden of proving that he div
bulla or Improve for of sale.).
❑not
purpose
❑I, u ownerofthe property, em exclusively conimctlng with licensed contractors to construct
51 ,
the project (Sec. 7044, Business and Professions Cade: The Contractor's License Law does not
J PROlLC.B.O. REPORT NO.
apply to an owner of property who bullae or improves thereon, and who contracts forsuch projects
r
with a contractor(a) Ifoarued pursuant to the Contractor's License Law.
MFGR. INSTALLATION SPECS.
O 1 am exempt under Sao a & P. C. for thle reason
,
owner oma
WORKER'S COMPENSATION DECLARATION -
APPLICATION DATE
VALUATION
PERMIT FEE
V ��
Building 77•
I hereby affirm under penalty of psdury one of the following declaration:
au, provided! have
❑ have entl will maintain a of the nate of Consent to eon -Insure for Workers Compensation, this
Section 37M a0lthe Labor Code ,for the periormancoof the work for whichthis
Permit is issued.
O
Seismic
❑ have and will m e Workers Insurance, as required by Section 3700
'of s
Performance f the work
the Labor Code, ion the pedormand of the work lar which this permit is Issued. MY Worker's
is I
-
Total
Compensation Insurance center entl Policy nvrMar are:
Carrier Policy No.
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
nal need
(Thinalneed not ba complated It me permit Is for one hundred tldl; ($100) or less.)
I ceraty Mat In Me performance of Me work for which this permit is lasued, I shell not employ "
any person In any manner as as to become subject to Me Workers' Compensation Lewy of Cell-
All roots Shall be inspected pNDpt6 any roofing material being
orals.
installed. If a roof is installed without first obtaining an
Date Applicant
,inspection, I E tn rAmnypp s for inspection.
NOTICE TO APPLICANT: II, after making this Certificate of Exemption, you should become
subject to me Workers' Campensatbn provisions of the Lobar Code, you meet "hwith comply
Applicant UO tan08 @[T7 will ICpmp lith all non point
with such provisions or his permit shell be deemed rewked.
L./�X LJ
Source'regUl S.
I cerllty mai I have read this appllcillon and state Mat the above Information is correct. I agree
to comply with all city and county oraruunee end state levee relating to building conatructanentl
OV t
hereby authorize representatives of this city to enter upon the above-mentionetl property for Im
-
spectlon purposes.
(We) agree to save, Indemnify and keep harmless the City of Cupertino epalnst Ilabllilles,
judgments, costs ark!expenaea which may in arty way accrue against mid City In consequence
LICANT
DATE
of the granting of this permit.-
PRE -INSPECTION:
PLYWOOD:
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