R-6124 PERMIT R_ 612 4,
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN IW DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
+' BUILDING ADDRESS '
Z/7 �^� ' T"� RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
p �1 VES ❑ N yes-I understand that a Clens A
NAME' /w � ` roof assembly is required
����7�> NO. E] lnft I.C.B.O.R
ADDRESS -7,/7�/�- 456k + "�D EXISTING ROOF COVERING
PHONE �/ T -5"3 NUMBER OF EXISTING COVERINGS 1i7
CONTRACTOR'S
NAME-/tf1';er/'AJ46 � TO BE REMOVEDSW""`l TO BE RETAINED xC
ADDRESS .s7 TYPE OF ROOF COVERING
CITY a ZIIP/' . EXISTING
PHONE BUILT-UP BUILT-UP ROOF ❑
LICENSE
NUMBER
��Z_ SPHALT SHINGLES E-1(!/
UCENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provlabrm of Chapter 9(mmmendng with Sadbn COD SHAKES
7000)of Dhislon 3 of Ute Business and Pro esslans Code,and an,license to In full force and
offal _
_ (+ O SHINGLES ❑
Lienee ClSao
3 Lic.Number •u Z '
Date _Z r o Contra &� P IFN) ❑
OWNER-BUILDE DECLARATION _
I hereby all that I am exempt from the Contractors Ucerl Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to %0 construct,after,Improve,dea lleh,or repair any structure,prior to its lseuarce,also requires the BUILT-UP OF ❑
applicant for each permit to Nle a signed Statement that he b acanuanl aed purato the provisions
of Ne Contractor's License Law(Chapter 9(commerxirg with Section 7000)of Dlvlelm 3 of the
. Business and Professes Cade)or that he Is exempt Nerelrom and the basis for Me alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil pensity of not more than five hundred collar,($50l
C]I.as owner of Me property,or my employees with wages eo Moir We compensation,will do W7C.
work,and Me structure a not Intended or offered for sale(Sec.7044,Business end Proles-
area Code:Tha Contactors License Law does not appy to en owner of property who builds orImprova,thereon,antl who does such work himself or through hie awn employees,provided Metsuch Improvements ere not Intended or eared for sale.It,howareq Ne bulltling or Improvementn Sold tWildowithin one impicyearourposelof sthe awrrer-builder will have the burden ofpmtng Met ha tlioOl� ��not build or Improve for purpose of sale.). �/❑I,as owner of me property,em exclusively comaci ng with licensed contractors to cansmuctme project(Sac.7044,Business end Pmlemlons Code:The Contradore Llcense Lew does not P .REapply to an owner of property who Wide or Improves thereon,end who contrecto for such projectswith a cont otos)licensed pursuant to the Contractors License Lew. PINSTALLATIC SPECS.❑I am exmpt under Sec. B A P.C.for this reason
owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following dedaration: /
❑1 have and will maintain a Certificate of Consent to self-Insure for Worker,Compensation, Building
as pro0ced for by Section 3700 of the Labor Cade,for the perlormanca of the work for which MIS g
per Iseuetl.. g-Z3-`J� G.�..sra a
have end will maintain Workers Compensation Insurance,as required by Section 37W of Seismic
t bar Cade,for the perrrmence of the work for which MIs permit is Issued.My Wall /. `/ �-Y
o pensation I�nsur�en�cyy�,a�m�S�er and Policy number are: j9 Total' /
Cerrbr�� Policy No. �nlo/'LS?,L PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(This secldon need not ba completed It the permit is for o hundred dollars($100)or lees.) � � � - 2-
I certay that In the performance of me work for which this permit Is Issued,I shell not emplay
became any person In any manner so as to amM
e subject to e Workers'Compensation Laws of Call- All roofs shall be inspected prior to any roofing material being
fornix. installed. If a roof is installed without first obtaining an
Date Applicant - inspection,I agree to remove all new materials for inspection.
NOTICE TO APPUCANT: U,after making If Cartiticate of Exemption,you should became Applicant understands and will comply with all non point
subject to the Worker,'Compensation provisions of the Labor Code,you must forthwith comply
with such provldons or this permft shell W deemed revoked. Source regulations.
I cartify that I have read this application and state that the above Information is correct agree
to comply with all city and county ardIrnmces and state lawn relating to bulldirg construction Brad All roof coverings to be class'C"or better.
hereby authorize representathaa of this chy to enter upon the above-mentioned property for In-
ep Wrrpc,es.
(Wee))agree to save,Indemnity and keep harmless the Clty of Cupertino ag Inst Ilebllldae,
judgments,costs and expereas which may In arty way accrue against ead Clry In corrsequerrce AT PLICANT DATE
of the granting of this peril
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 '