R-6488 PERMIT R_ 6488
APPLICATION FOR CITY OF CUPERTINO NUMBER
- INSPECTION DIVISION PERMITEXPIRATI N
REROOF PERMIT (408) 777-3228 - PERMIT EXPIRES IF WORK IS NOT STARTED '
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDINGADDRESS _/
7'7-., �/ G e /h/�' RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes-I Understand tot a Glass A
NAME roof assembly is required.
NO ❑ Initial I.C.B.O.N
ADDRESS EXISTING ROOF COVERING
Z
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S _
- Z
NAME "/ G M I /?oOGj (o_ _G,✓G. TO BE REMOVED TO BE RETAINED
ADDRESS '7t+, s,�. S� ,Tore y� TYPE OF ROOF COVERING -
Cltt 8 ZIP !/ EXISTING
PHONE- Z4z-76y� BUILT-UP ROOF �§
LICENSE
NUMBER ASPHALT SHINGLES
!i 7
LICENSED CONTRACTORS DECLARATION
I hereby al Mat I am licensed under prorinione of Chapter a(commencing with Section WOOD SHAKES ,
7000)of Division 3 of the Business and Professions Code,and rtty license Is In lull force and -
affect. WOOD SHINGLES C3Ucenea Class Uc.Number ZN37Z
Date �/ �l6 / f Contractor OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that I am exempt from the Conlmctora License Lew for gra following reaul
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
mr Z,after,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF O� O
applicant for such permit to file a signed statement that he is licensed pursuant to me prov atons Q
of the Contractors Ucense Law(Chapter 0(commencing with Section 7000)of Division 3 of the r1 D
Buelnese and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES U
exemption.Any violation of Section 7031.5 by any applicant ku a permit sublacis the applicant to
a civil penalty of not more than five hundred dollars($500).): (t
C]1,as owner of the properly,or my employees with wages as their eNo compensation,will do WOOD SHAKES APR 1 I99
the work,and the structure Is not Intended or offered for sale(Sac.7044,Business and Proles-
sone Coca:The Contractors License Law does not appy to an owner of property who builds or WOOD SHINGLES
Improves thereon,and wic does such wwk himself or Mrough his own employees,rzdad Thai ❑
such Improvements are not Intended or offered for sale.M,however,the building or Improvement
Is sok within one year of completion,Me owner-builder will have the burden of proving that he di OTHER(SPECIFY) BY
not WIM or Improve for purpose of sale.).
❑I,as owner of Me property,am exciuslvety coniractlng with IMeneed contractors to conatrud
the protect(Sao.7044,Business and Profastlons Code:The Contractor's Llcenae Law does not PROVIDE I.C.B.O.REPORT NO.
appy to an owner of Property who builds or Improves thereon,and who contracts for such projects
wlth a contractor(e)licensed pursuant to tie Contractors License Law.
❑I am exempt under Sec. ,B B P.C.for Ws reason PROVIDE MFGR.INSTALLATION SPECS.ND-?Ill
C,dr fail V
Owner Date APPLICATION 0ATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECIARATION
I hereby affirm under peneity of perjury we of the following declaration:
❑I have and will maintain a Certificate of consent to self-Insure for workers Compensation, / r BUlldinga�f���
en provided for by Section 3700 of the Labor Code,fon the performance of Me work for which this /6� Z® -730permll le issued. / Z�
❑I have and will maintain Workers Compensation Insurance,as required by Section 37W of Seismic
the Labor Cada,for the performance of the work for wti T Mis permit le Issued.My Workers Total .2=61—InwLmnce cancer and Policy number�e �J�
Carrier bt iW/2t/S /YA» 1 I potfoy No. .� ✓R 0 il�' PERMITAUTORIZATIOl DATE
CERr1FICATE OF EXEMPT) FROM WORKERS' ^
COMPENSATION INSURANCE N.C.0 _� Y
(This section need not be completed If the permit Is for ons hundred dollen(5100)or lees.)
I certify that In the performance of to work for which this permit Is Issued,I of not amtoy -
say person In any manner so as to become subject to the Workers'Compenal Lowe of heti- All roofs shall nspecte prior to any roofing material being
fornia. Installed. If Cot is Installed without first obtaining an
Date Applicant inspection,I gree to remove all new materials for inspection.
NOTICE TO APPUCANT: If,after making this Cor fhcate of Eaempdon;you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must lorthwdh comply
wlth such proviekms or this permit shall be deemed revoked. Source regulations. -
I canny that l have read this application print state Met Me above Information Is correct.I agree
to comply with all city and county ordinances and state Mws relating to Wilding constructfon,end All roof covens s toA class"C"or better.
hereby authorize represontetrves of this dry to enter upon the above-mentioned property for purIn-
spe 'r—�� _ ?f
llan poses.
(We)agree to save,Indeirl al keep harmless fine City of Cupertino against IIablild".
Judgments,costa and expenses which may In any way accrue against sold City In consequence SIGNATU OF APPLICANT DATE
• of the granting of MIs 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 ACCESSTO ROOF SHALL'BE PROVIDED FOR INSPECTION'
OFFICE COPY