R-6388 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R" 63 S H
INSPECTION DIVISION PERMIT EXPIRATION -
REROOF PERMIT - (408) 777-.3228 � PERMIT EXPIRES IF WORK IS NOT STARTED
• _ WITHIN DAYS PERMIT ISSUANCE O
180 DAYSS FROM LASS T CALLED INTI
SPECON..
BUILDING ADDRESS v/
RESIDENTIALCOMMERCIAL - OTHER
OWNER'S �— HAZARDOUS FIRE AREA
!/ YES ❑' It yes—I understand that a Class A
NAME—_- TDA'i� rootas ,Zly isrequired. -
. NO
ADDRESS 4i////7161.F.liz - .EXISTING ROOF COVERING
PHONE % �' NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
l TO BE'REMOVED TO BE RETAINED
' NAME ZI�G. /YJ O/i
ADDRESS /�/7DL •/ /-g /w _'SUTYPEOF_ROOF COVERING
CITY 8 ZIP ! S �/} (�•. !.(J �7/�/O
- EXISTING -
PHONE 4g�V BUILT-UP ROOF ❑',
LICENE
NUMBER ,Z 7,/W ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am Ilctnsed under provisions of Chapter B(commencing with Section WOOD SHAKES
]000)of Division 3 of Na Bases"and Professbne Coda,and my license Is In full force and
effect. nn / WOOD SHINGLES
acmes Class� uc.Number �J� ❑
p ;' All0 OTHER (SPECIFY) ❑
Date �— �� � Contractor � �
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's following
License Law for the reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,improve,coal or repair any stimmwat,prior to Its Issuance,also requires the BUILT-UP ROOF
applicant for such permit to file a signed statement that he Is licensed pursuant to the provleleas
of the Contractor's License Law(Chapter B(commenting with Section 7000)of DMabo 3 of the
Business and Professors Cade)or that he Is exempt therefrom and the basis for the albged ASPHALT SHINGLES ❑
exemptlad.Any violptlan of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty,of not more than five hundred dollars ,
❑I,as owner of the property,or my empbyeas with wages as their sole compeneatlon,will do WOOD SHAKES ❑
the work,and the structure is rot Intended or offered for este(Sec.7044,Business and Pal
dons Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who craps such work himself or through his own employees,provided that ❑ 'TT/(,L
such Improvements are not Intended or offered for sale.If,however,the building or Improvement /
Is sold wirdle me year of corrosion,the owner-bulkier will neve the burden of proving that he Gd OTHER(SPECIFY)
not b 1,as
improve ler property,
of eels.).
El I,ec owner ofthe property,am Professions
construct
Its
i mien(Sec.7044,Business aM Pr or Improe Code:The and who conlicense Law doesnot PROVIDE LC.B.O. REPORT NO.
app a to nt owner of propertywho balite or improves thereon,and who contracts for such profane
vdmacmexempt 11cemaid Sepursuant to the Contractor's acerous Lew. PROVIDE MFGR. INSTALLATION SPECS.
I em exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the fcibwing decmratlon: /
I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation,son, Building /�
as provbed for by Sanlon 37W of the Labor Code,for the performance of the work for which thls
permit Is IUW. Seismic /
sects,
will maintain Worker's Cao work for Insurance,hickthis as permit is Is by Section Worker's /
tour Code,for the performance of the work for which this permit R Issued.My Worker's Total �I
Compensation Insurerce carrier and Pdlty.number ere: �� '
Carder �/� /�� PolicyNo`el/� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N. ]
(This settled rated not be completed If the permit Is for one hundred dollen(5100C{)or loss.) - -� 9
I certify that In the performance of the work for which this permit Is Imi I shall not employ (D
any person In any manner so as to became subject to the Workers'Compensation Laws of Cali- All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
sur ojleciio Me Wu�rkers'Coompenssentlon pvalaioonls of t o Latbeor Cone,yolu muusst forbthwith�compy Applicant understands and will Compl ith all non,point
with such provisions or able permit shall be deemed revoked. source regulations.
I certify that I have read this application and state that the above Informal Is torten.I agree �,,(J
to comply with all city end county ordinances and state laws relating to building construction,and All Poorfp erin to Aor better.
thereby anhorize representafives of this city to enter upon the above-mentioned property for In- / I
epectlon purposes. (/ —7
(We)agree to save,Indemnity and keep harmless the City of Cupertino against larelllties,
judgments,caste end expenses which may In any way accrue a0alrast sem City In consequence NATURE OF APPLICANT DATE
of Ma encs'granco of andthis 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 "