R-6201 . PERMIT
APPLICATION FOR CITY of cUPERTwo NUMBER R" 6201
INSPECTION DIVISION PERMIT XPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED'
- WITHIN 100 DAYS OF PERMIT ISSUANCE OR
' 100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/O1,0OO —./O441O F0Q7)+/4LL RESIDENTIALJ�_C.OMMERCIAL OTHER
OWNER'S I.rN^
T• '.11/NS R. ��►A? J VES ❑ byes—I understand III aClassA
NAME w ,mW assembly IS m4ui ad. '
NO ❑ Initial I.C.B.O.N
ADDRESS .EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COV RINGS
CONTRACTOR'S r
NAME �1✓A`J /—� � TO BE REMOVED = TO BE RETAINED
ADDRESS -
TYPE OF ROOF COVERING
CITY&ZIP
EXISTING -
PHONE BUILT-UP ROOF ❑
NUMBER .LICENSE2�58��, ASPHALT SHINGLES,
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(corral p with S on WOOD SHAKES
7000)of Division of the Business and Professions Code,and my license Is In full force
effect.
All 129El4 WOOD SHINGLES
License Class—,Uc.Number � � ��/ ^ �i 1
Date contractor Q OTHER(SPECIFY) ❑
OMER-BUILDER DECIARATION ePROPOSED
I fermy affirm that I em exempt from the Cmtreddrs Ucense Law for me following Sen. '
(Sec.7031.5,Badness and Professions Code: Any city or county whlch requires a permit to
mnstmct,alter,Improve,demolish,or mpelr any structure,prlortolslaeuence,alsorequlresiha BUILT-UP ROOF Elj
eppl cam for such permit to IIIc a signed statement Met he Is Ilcensed pursuant to the provisions
of the Contractor a Lkxmse Law(Chapter g(commencing with Srctko 7000)of Oldslon 3 of the -
Business and Prolra ims Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption Any Nolatlon of Section 7031.5 by any applicant for a permit subjects the applicant to
e chill penalty of not mare then five hunered dollen($500).):
❑I,as owner of the property,or my employees with wages ee their Sola wmpeneatbn,will do WOOD SHADES ❑
the work,and the eVuctum Is rot Intended or offered for sale(Sec.9044.Suelneee and Protea- -
slons Code:The Contin Licamse Low does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for Sebe.II,however,the building or Improvement
IS Sold whhbn me year of completion,tha owner-builder will he"the burden of proving that he did OTHER(SPECIFY) ❑
not bUld or Improve for purpose of Sale.).
Las
P,�,asOwner of the property,am exclusively cmtmcdn g with licensed contractors to construct '
Oct(Sec.7044,Business and Profeselms Code:The Cmiractor's License Lew cora not PROVIDE I.C.B.O.REPORT NO.
appy to an owner of property who bullae or Improvescomradects
thereon,and who for such proje
wkm a contmcens)licensed pursuant to the Contractors Ucense law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sac. ,B It P.C.for this reason'
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of per{ury one of the following dedeletion:
❑I have and will melnt37 a of the"b r Consent to self-Insure ler Workers Compensation,which
this 1 C/A w �� t ) Building
permit is ecforMSectkm 3]00 of the Lobar Code,for the performeree of the work for which this f+ (y��Y1_/
permit k Issues. '
❑I have and will maintain Workers Componsatlan Insurance,ee required by Sadlm 37M d /7 Seismic
the Labor Coce,for Of performance of tha work for which geWorkers
permit le Issued.My Worke - �.J
Compersellon Insurance carrier end Policy number are: f Total
cud., .S 7Arq, FLl/1✓�� Pal No. _ RMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM W ORKERS'
COMPENSATION INSURANCE N.C.0 r
(This eSudun need tot be completed it One permit Is for one hundred dollars($100)m leas
I candy,that In the perlonmar of the work for which this Pump Is issued,1 shell ret employ
any person In any manner w as to become Subject to the,Workers'Compensation Laws of CalFI roofs shall be inspected prior to any roo mg aterial being
fornba. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection'.
Su NOTICCE QOVAPPL(CANT: It,
after
kiinfalo Io o�me tate of oar Fyou should become Applicant.understands and will comply with all non point
you must forthwith comely
with such provfelons or this permit"IDbe deemed revokel source regulations.
I cersty that I have read thio application and state that ge above Information Is conect.I agree
to comply with all cry,and county ordinances and state lame relating to building construction,and
•All roof coverings f0 be CIBSS"C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
epecdon purposes.
(We)agree m,seve,Indemnify and keep harmless the City of Cupertino epeln rt Ileblllties,
Judgments,mets and expenses which may In any way accrue against Said Clty In consequerwe
410 of Me glendng of this pump. SIGNATURE OF APPLICANT DATE .
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