R-6661 PERMIT R_
6661
APPLICATION FOR CITY of cuPERTINo NUMBER
REROOF PERMIT 'INSPECTION DIVISION PERMIT EXPIRATI N .
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
VIT SIDE CO M CIAL - OTHER
OWNER'S -
S ❑ If luod. t o Class A
NAME II ILrodse �ra u i.
ADDRESS / (2-71 S /X///�(', ?_74546 EXISTI OOF
COVERING
PHONE - T v v S
CONTRACTOR'S
NAME � N TORE REMOVED 70 BE RETAINED
ADDRESS U - ,.�,I� TYPE OF ROOF COVERING
CITY a ZIP EXISTING
m' '
PHONE BUILT-UP ROOF
LICENSE4�./,
NUMBER �G LC ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
'I hereby,of irtn Mat I em licensed urger wovfslone of Chapter g(c acing with WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In full farce and
sees. � ,a D SHINGLESLiDerm ❑
enact. less "'� Lk.Number �2
r nl�irrLo O (SPECIFY) ❑'
Date Contractoror OF T— _
NER-BUILDERDECLARATION PROPOSED
I hereby affirm that 1 em exempt from Me Contractor's License Law for the blowing realm.
. (Sec.7031.5,Business anal Professions Cade: Any city or bwnry which requlres a permit to
ro = - .
cstrud,after,improve,demolish,or repair any structure,prior to Its lasuance,also requires the BUILT-UP ROOF
applicant for such permit to file a signed statement Mal he is licensed pursuant to Me provisions
of the Contractors Dcense Lew(Chapter I(Cmr mendrg with Seotbn 7000)of DlvW.n 3 of the
Business and Professions Code)or Met he Is exempt therefrom and the basis for Me alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a Parma subjects en applicant to
e CMI penalty of not more Men Me hundred dollars(5500).): WOOD SHAKES
❑1,as owner of the property,or my employees with wages as MW
air sole compensation,will do - ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,.Business and Pmfes.
alone Cade:The Contractor's License Law does rot apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own amployaes,provided Met ❑
ouch Improvements are not Intended or offered for sale.ll,however,the building or Improvement
is sad within one year of completion,the owner-bulkier will hese the burden of proving that he tlk OTHER(SPECIFY) El
build or improve for purpose of sale.).
❑I,mowner of the property,am exclusively mntrectlng wfth licensed contractors to construct
the project(Sec.7044,Business and Prof xislors Cade:The Contractors License Lew does not PROVIDE LC.B.O.REPORT NO.
apply to an owner of property who Wide or Improves thereon,and who contracts for such projects -
with a contractors)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B E P.C.for this reesan
441io!�E Date
nW... yh WORKER'S COMPENSATION DECLAMTION--T--r�— APPLICATION Di VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declamtion: � v
[]I have and will maintain a Certletata of Consent to self-Insure for Workers Compeneatko, /
aft,provided for by Section 3700 of Me labor Coos,for the on
perlormce of the work for whichBllild ng this .:z
permit Is Issued.
❑1 hese and wit maintain Workers Compensation Insurance,as required!by Section 3700 of Seismic I
Ute Labor Cole,for the pertormence of the work for which tNe permit is issued.My WoMro •�7.7 �^n
Compensation Insurance terrier arta Policy number are: Total / (S_LL
Chortler Palcy No _ PERMIT AUTHORIZATION !DATE_
CERTIFICATE OF EXEMPTION FROM WORKERS'. �1
COMPENSATION INSURANCE N.C.I] l /
(This section need not be completed 4 Me permit is for one hundred dollars($100)or less.) r,
I cortfty that In Me performance of the work for which Mia perand Is Issued,I shell not employ
any pennon In any manner so ea to became subject to the Workers'Canpenaatbn Laws of Cali- All roof.. she I be inspected prior to any roctfing material being
fornix. ,/' installed. If a roof is installed without first obtaining an
Data Applicant(� • LLG- inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making MIs Certificate of Exempnm,youli b
aecome ' Applicant understands and will comply with all non point
subject to the Workers'Compensation provlalons of the Labor Code,you must forthwith comply
with such provlsions or this permit shaftbe deemed revoked. source regulations.
I ceroty Mat I have read this appkabon and state that the above Information Is mrtnn.I agree
match,tmatch,with all cry,and county ordinances and state laws relating to bulldirg construction,and All roof covenn s to be class"C"or better.
hereby autnim oriza aprasMtNee enof the city to enter span the above-mentioned property or in-
hereby pur.
(We)agree to save,Indemndy,and keep harmless the City of Cupertino against IlebWties, ♦
judgments,mea and expenses which may In any way accrue against said Gty In coarmuence SIGNATURE OF APPLICANT DATE
of Ogre
of this
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