R-6250 PERMIT R. 6250
.
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
' 100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS rr,�//''
rt RESIDENTIAL—K--COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes-I understandthat a Clens A
NAME I ") n .roof assembly is required.
NO ❑ Initial I.C.B.O.Y_
ADDRESS - EXISTING ROOF COVERING
PHONE LCIJV — NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED__L_TO BE RETAINED
NAME
ADDRESS C TYPE OF ROOF COVERING
CrvszlP- _LY J t�✓If "`�`�Z EXISTING
PHONE - - BUILT-UP ROOF ❑
LICENSE
NUMBER Q SP,41N 0 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that 1 em licensed under provisions of Chapter 9(commencing with action WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,end my license a In full force and
eeeac / 16POD SHINGLES ❑
Lkenae C Llc.Number •
,.a PECIFY) E]Date it 2 Contrenor 1 CD. E
OWNER-BUILDER DECLARATION
I hereby affirm that I em exempt from the Contractors ucerme Law far the bllowinp reason. POSED
(Sec.7031.5,Businew entl Professions Code: Any city or county which requires a permit to
cwaaruca,after,Improve,demolish,or repair any structure,pror to Its Issuance,also require the �UILT--UP ROOF ❑
applicant for such permit to Ne a signed statement that he is licensed publ to the prods ons
of filo Connectors license Law(Chapter 9(commencing with Section 7000)of DMsbn 3 of Na
Business and Professions Code)or Net he U exempt Iherefrom end the basis for the alleged ASHALT SHINGLES ]
lip exemption.Any vlolatlon of Section 7031.5 by any applicant for a permit subjects the applicant Io
a dull penalty of not more than I"hundred ddlars($500).): '
❑1,as owner of the property,or my employees with wages as their able compeneatlon,will do WOOD SHAKES ❑
the work,and the structure is not Intended or offered for sale(Sac.70M,Business and Proles.
cions Cade:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,arm who does such work himself or through his own employees,provided Nal
such Improements are not Intended or offered for sale.If,however,the but Ming or Improvement
b sold within ane year of conpledon,the owner-bulker will have the burden of proving abet he dill OTHER(SPECIFY) ❑
not bulltl or Improve for purpose of sale.).
❑I,as owner of the property,am exclusNely contactlng with licensed contractors to construct
the project(Sec.70 ,Business and Profession,Code:Tiu Contractors License Law roes net PROVIDE I.C.B.O.REPORT NO.
appy W an owner of property who butltla or Improves Maroon,and who countable for such projects
with a contractors)licensed pursuant to the Corneal License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under §L" ,B&P.C.lar this reason
Owner WWJ RIKER Cok�NSATI ITEC aON APPLICATION DATE VALUATION PERMIT FEE
1 hereby eHlrm under M" Ify of perjury one of Ne follow! ration:
have and win ma na¢����ryn��//,rep QQnn fta for workers Compensation, Building
eep❑rwidedlorby Sect nW000fV1A Eab�p . Wrl co of the work for wehich this [� /
permit Is issued. 0 r �j 1b 0�'� Seismic r/O
❑1 how and will m r In Workers Gcm pensatbn Insure a required by Section 370 of t
the Labor Code,for Ih rmame of the work far which t s rmlt Is Issued.My Worker's LL
Compensation Insu 'cy number aro: Total /`-7 0
Cerner —� �- �1- q -;t PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C{]
(This sect on need rot be competed I the permit le for one hundredtldlere($100)or less.) r
I certify that In the padormaroe of Ne worx for which this permit Is Issued,I shall not employ
any peIn ny manner se as to become ebtpecrm Ne workers'Cbmpersanan 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 I z q2( Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Examplion,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensatlon prwlhons of Ne Labor Collet you must t rthwith campy
wish such prbvla errs or this permit shell be doomed rewked. source regulations.
I certify that l hew read thio application and state thea the above lnformedon Is correct.l agree
to comply wlih all cityentl county ordinances and state laws relating to bulltling wnstruction,and All roof coverings to be class b or better.
hereby eueodze representatives of Nis dry to enter upon the above-mentioned property,lor In. - l
specrior,Purposes.
(We)agree to save,Indemnify entl keep harmless the City of CupeNrro apelnst liabilftbs, F� / '
jud mens,coats and expenses which may In any way accrue against sem Oily In ccnaequence NATURE OF APPLICANT DATE
of the PECT of N4 permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
-` INSP. DATE - INSP. - . DATE INSP. DATE
TEAR OFF INSPECTION: -� ,{)))� B - BATTENS: FINAL:
INSP. DATES INSP. '—' DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY