R-6177 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO . NUMBER 617 7
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT '(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1W DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
/'1 YES ❑ If yes—I understand that a Class
NAME�_ [ - root eaverrubly Is required.
ADDRESS / ���` NO. Ir O �4 I.C.B.O.M
J� EXISTING ROOF COVERING
PHONE �.L(-f — NUMBER OF EXISTING COVERINGS
CONTRACIDO
TO BE REMOVED TO BE RETAINED
NAME Y
ADDRESS TYPE OF ROOF COVERING
cm a ZIP !� (? 2 EXI N
PHONEw � ( v�/ k �Ji{C �/ 1 BUILT-UP ROOF ❑
LICENSE
NUMBER , ASPHALT SHINGLES
LICENSED=NTRUiuCTORS DECLARATION
' i hereby affirm that I em licensed under.provblons of Chapter a(oornmencing with Section WOOD SHAKES /��J—/❑ '
7000)of DIVIMon 3 0l the Business and Probesl.ns Code and my Ilcensa is In full brce and
elect.
WOOD SHINGLES ❑ '
License Cie Lic.Number
Data contrast., OTHER(SPECIFY)
ER-BUILDER DECN PROPOSED
1 hero of it I e e met from the Contractor's License Law for the bl rescan. ,
(Sec.]031.5,Business and Professions Cci A"city or county which repulms a permit to
N
W,anni after,Improve,demolleh,or repair any ift cute,prlor to its issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to his a signed statement that he Is licensed pursuant to the provisions
of the Convactoes License Law(Chapter s(mnlrnendnp with Section]000)of Divleton 3 of the
Business and Professions Code)or stet he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
• exemption.Any vbtatbn of Section 1031.5 by any applicant for a permit subtacte the applicant to
a civil penalty of,rot more than five hundred forum(f5W).): WOODS ES
❑I,as owner of the property,or my employee,with wages as their We compensation,will do ❑
the work,and the mruoture Is not Intended or offered for sale(Sec.1044,Business and Proles- Q
alone Code:The Contractor's License Law does rot apply to an owner of property who Wilds or WOOD LE
Improves thereon,and who do"such work himself or through his own employees,provided that
such Improvements are not Intended or seared for salla.II,however,the building or Improvement J�/��.
Is sold within one year of completion,the owner-bu Wer will have the Wrden of proving that he did OTHER PEGW� 1419
not build or Improve for purpose of sale.). n
[:11,as owner of the property,em emiusNely contracting with Ilcensed contractors to construct J
the project(Sec.1044,Business and Professions,Code:The Contractor's License Lew does not PROVI Fg LC.B.O.REPORT N
apply to an owner of property who Wilde or improves thereon,and who cmirecb for such projects Y
wnn a conbactor(s)IlcenaW pursuam to the Convectors License Law. PROVIDE ' CATIONS ECS.
❑I em exempt under Sec. ,B&P.C.for Ihg,reason
owner Data _ APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury arra of the following doctorates: �•�
❑I have and will maintain a Cerdlkate of Consent to eelbinsure lot Workers Compensation, BUlldln
as provided W by Sei 3100 of the Labor Code,for the perlormands of the work to,which ties �
permit is issued.
C]I haveand!wig maintain Workerm
s Coparra lion Inourance,as required by Section 3100 of /� L=/T,/J/J' Seismic Z
_the Labor Code,for this performance of IN work for which I"permit Is Issued.My Workers
C.mpensatbn nsur car er and Policy number are Total/6 �zo
Carrier � ted•-r �.roticy Na.MI&YQ-1 3& PERMIT AUTHORIZATION TE
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ _
(Titus eedlon need not W comH M
pletetl e permitIs foror one one hundred dollars($100)or IaseJ (!
4 cantly that In the p arm of the work for which thus rmIt Is tallied,I shall rot employ
any person In any er w es become su Iha ,kers'Compen t sus of Dad- II roofs shall be inspected prior to any roo ing aerial being
fors /"�,L, ,
>y1 ' stalled. If a roof is installed without first obtaining an
Date ° $IWan inspection,I agree to remove all new materials for inspection.
NOTICEer making this militate of Em eon you should m Applicant understands and will comply with all non .int
sublect to the Workers'Conpensodon iav ons of the Labor Cod ,you moat forthwith wnply PP P Y P
with such provfatona or this permit ahai deemed revoked. Source regulations.
I cardfy that I have read des apphcabon and state that the above informal u coned.I agree
Io comply with all city and fawn county ordinances entl state farelating to Wilding constmcuon,antl of enngst class' r. ^
hereby authorize reprommativas of this city to enter upon the above-mentioned property far In- U
epecdon purposes. f
(We)agree to save.Indemnity entl keep harmless the City of Cupertino agonst Ilebli les, l
of grandtg of Nle pennleft B8 wNch may In a^Y way accrue against ealtl City In consequence Sl A E PLICAN D E
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