R-6508 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R' 65 0 8
REROOF PERMIT - INSPECTION DIVISION PERM IT EXPI RATION
(408)7773228 PERMIT EXPIRES I
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDINGADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S n - understand
HAZARDOUS FIRE AREA
NAME A-l��n d 1 �GLL�\ • `. - VES ❑ rod esde rderst req sled. sA
'� 1 ' NO ❑ Initial I.C.B.O.A
I )0.✓L ca � �{ V I J EXISTING ROOF COVERING
ADDRESS
PHONE C9J� l ' U JC� NUMBER OF EXISTING COVERINGS '
CONTRACTOR'S ^ • ` O
NAME- 00 ( cu� IJ a� TO BE REMOVED TO BE RETAINED
DRESS 7® --7 %l�_D I3 VVV\� ) - TYPE OF ROOF COVERING
CITY BLP JO (`'iJ �WI !J4. 2�-
PHONE 2 E BUILT-UP ROOF
LICENSE W=1
F-1NUMBER ASPHALT SHINGLES
DCENSED CONTRACTORS DECLARATION
hereby affirm that I em licensed under provislons of Chapter B(commencing with Section WOOD SHAKES �^
700 0)of Dlvlsbn 3 of the Business and Profeaeloe Code,and my license is in full force and
e"eat' e 3 02273 WOOD SHINGLES
License Claes Llc.Number
j_-l_�, .OTHER(SPECIFY) +l" ❑ _ ., ...nn
Data I Cantraaor r+ N
I Ht 1 1 '
OWNER-BUILDER DECLARATION i
I hereby affirm Chet I am exempt from the Contractor's License Lew for the following reason. PROPOSED u
(Sec.7031.5,Busine ra and Professions Code: Any dry or county whloh requires a permit to
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF Elmit
applicant for such perto Iib a algned statement that he Is Iholmal pursuant to the prwdslars ';1 at Me the Contractors License Lew(Chapter a(commenclng with Section 7000)of DMuon 3 of the
• Business and Professloth
ns Cade)or at he Is exempt ttUahan and the deal,for the areged ASPHALT SHINGLES'
exemption.Any yloladon of Seddon 7031.5 by any applicant for a permit subjects the applicant to
e cMl pecalty,of not more then flue hundred dollars(5500).):
❑1,as oemer of tiro property,or my employees with wages as,their sole companeatlon,will do WOOD SHAKES El
the work,and the structure is net Intended or offered for sale(Sec.7PM,Business and Pnbfes-
elom Cade:The Contractors Uconse Law does not apply to an osier of property who builds or WOOD SHINGLES
Improves thereon,entl who dime such work himself or through his own employees,provided that El
such improvements are not Intended or offered for sale.If,however,the bulkling or Improvement
is sold witNn one year of completion,the owner-bulkder wit have the burden of proving Chet he olid OTHER(SPECIFY) ❑
not build or Improv,for purpose of sale.).
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.lona,Business and Profesalons Code:The Contractors ucenee Lew does net PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bulls or Improves thereon,and who contracts for such projects
with a contraw r(s)llcanaed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Bac. ,B 8 P.C.for this reason
Owned - Date APPLICATION DATE VALUATION PERMIT FEE.
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the lollov g dacleratlon:
❑1 have and will maintain a Certificate of Consent to setiansure for Worker's Compensation,_ // BUlldlnyJ
as provided for by Section 3700 of the Labor Cade,for the performance of the work for which this
Iwrms Is Issued. ZD
❑1 have and will maintain Workers Compensation Insurance,as rewired by Smash 3700 of Seismic
the Labor Code,for the performance of the wok for which this parr is fnsuatl.My Workers Total / 12
Comperset Insurance carrier and Policy number are:
f_1 WO
Carrier a`1 Let EA5tRtAnlaCP Policy No s- PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NC{]
(Thio section need net be competed H the permit i,for one hundred dollar,($100)or less.)
I cantly Vel In the performance of the work for which this permit M Issued I shall not employ I111 / ll
arty parson 1n any manner so as,to baaon,e subject to the Workers'Compensation Laws of Call- All roofs shall be inspected prior to any roofing material b6ing
fofn1a. installed. If a roof is installed without first obtaining an
Data Applicant inspection,l agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should became Applicant understands and will comply with all non point
Subject to the Workers'Compensation pro lslons of the Labor Code,you must forthwith comply
with such provisions or this permit shall be deemed revoked. source regulations. -
I certlfy that I have reed this application and state that the above Information Is correct.I agree
to campy with all city and county ordinances and state laws relating to building constructor,and All roof coverings to Ile cla 'or better.
heraby authorize representatives of this city to enter upon the abwo-mert oned property for In- - -
Pa
spection purposes.
(We)agree to save,Indemnify and keep harmless,the City of Cupertlne agalnal Ilabilltles,
Judgments,e OranVrg of this pertpermit.coats and expenses which may In.any way accrue against sold CityIn consequence SIGNATURE�OF APPLICANT DATE
of
PRE-INSPECTION:. PLYWOOD: IN-PROGRESS:
INSP. DATE If 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 -