R-6221 PERmrr
CITY OF CUPERTINO NUMBER R 6221
APPLICATION FOR INSPECTION DIVISION PERMIT EXPIRATION .
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• - 180 DAYS FROM UST CALLED INSPECTION.
BUILDING ADDRESS �7 /�(//,/S / L / 0✓ RESIDENTIA COMMERCIAL OTHER
OWNER'S l{ /�/ / err' HAZARDOUS FIRE AREA
NAME / 2[ nit v ME l.�V� VES ❑ roof a I t noty is reclumand ef a Class A
tool assmrlbly B requkeni
NO ❑ Initial LGB_.O.N
ADDRESS C'� EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
COMAACTOR'S
NAME /5", v TO BE REMOVED TO BE RETAINED T/
ADDRESS TYPE OF ROOF COVERING '
CITY s zip cyp EXISTING
PHONE 36'x. �i ?' BUILT-UP ROOF ❑
LICENSE l ,r Z,:
NUMBER - ' ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION '=
I hereby afllmn that l am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of Me Buelnem and Professions Code,and my Ikame k In fu Ice and
eH�"' (/f WOOD SHINGLES
lme y ConUc.Number
I-cense C 6 7
Date • tractor
OTHER(SPECIFY)
'
OWNER-BUILDER DECLARATION PROPOSED ��/
I hereby affirm Met I am exempt exet from the Calltraetarm e I-Icenlaw lath
r e following reason.
(Sec.7031.5,Bueinms and Prolsaslans Cade: Any city or county witch requlrm a perat to
construct,alter,Improve,demdlsh,or repair any structure,prior to Its Issuance,also requtrm the 'BUILT-UP ROOF
applicant for such permit to file a sgrtad statement Chet he Is Ikenssd pursuant to the prooftft"
of the Contructor's License Law(Chapter 9(commencing with Section 70(0)of Division 3 of the
Business and Prolesslons Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Se on 7031.5 by any applicant for a permll subjects the applicant to
a civil penalty of not more then five hundred dollars($500).):
C]1,mw
owner of the property,or my employees m with wages their Col.compensation.111 D SHAKES ❑
the work,end the structuro b rat intended or offered Wrests Sec.7C usinmis', oleo-
eloneCade:TheContrectorsLkenmLawtlomrwlappytoenowne ¢tp try or )OD SHINGLES ❑
Improves thereon,end who does such work h4rue11 or through hlo own s,Provided that
such Improvements are not Intended or offered for sato.8,however,Ihing or Improvement'
is soldwhhinme ymrofeompletlon,the owner-0ullderwill have the Ou blp�711d11is eltl 19 e 'HER(SPECIFY) ❑
not build or Improve for purpose of sole.). Mrs"�1 //.r/ .7 0
❑I,asawneroftheproperty,amexcl scaly a tracingwlthllcen ntractorstoconstrucl
the project(Sec.7044,Business and Professions Cada:The Contract x ansa Law doss net r IOVIDE I.C.B.O. REPORT NO.
appy to an owner of property who bullas or improves thereon,end rrfw sheds for such prgects
with a contracior(sl licensed pursuant to Me Cantaictor's License gy
❑I am exempt under Sec. PROVIDE MFGR.INSTALLATION SPECS.
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
'I h relay affirm under penalty of perjury one of the fdlowing declaration: F-�
I have and will maintain a Cedlflcale of Consent to self-Insure for Workers Compensation, BUIIdIn
as provided for by Section 3700 of the Labor Code,for the performance of the work lar which lhu, �y /7� /� g D
ZI
permit h vsued. /S / / 1"
�(f S81SR11C
❑ have arta will melntaln Workers Cortpansa8on Insurertde,as regWred by Section 3700 of (/ L
_the Labor Cade,for the gerformill of the work for whk:h.thls permit Is Issued.My Workers
Compenmtbn Insurance carrier and�Pollcy number are. - Total
Carrier '7y� /`7Serry� policy N]3y PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C/]
(TINS section rroed not be completed 8 on
tethe Permit is for e hundred dollare($1 de)a Zeal �.
I tartly that In Ute performance of the work lar which this Permit Ne Issued,I shall net Pal
any person In any manner so m to become subject to the workers'Cos ensedon 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
Dale Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: IL after making this Certificate of Exemption,you should become A licant understands and will comply with all non point
subtact to the Worked Compensandn provisions of the Labor Code,you must forthwith campy pP P Y P
with such provisions or this permit shalgbe dmmed reroked. Source regulations.
1 certity that I have reed IME application and state Mat the above Information Is correct.I agree
to comply with all city a a county ordImnce3 and stale laws relating to building construction,and Ail roof covering,-4o be class"C'or better.
hereby authorize repremntatives of this city to enter upon the above-mentioned property for In- iy
epectlon purposes. - O •y/
(We)agree to save,Indemnity end keep harmless the Cly of Cupertino against Ilabllhles,
Iudgm
mta,coats entl expenses which may In any way accrue against Bald Clry In conmquance NATURE OF APPLICANT DATE
. of the granting of this permit.
PRE-INSPECTION: PLYWOOD: Or IN-PROGRESS:
If DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE If DATE INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY