R-6083 PERMIT
APPLICATION FOR CITY OF CUPERTwo NUMBER R" 6 O H 3
INSPECTION DIVISION PERMfT EXPIRATIOt
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS
- IW DAYS FROM IAST CALLED INSPECTION.
IO 07`' ✓ �'V'�� C' YJ (,/ r RESIDENTIAL COMMERCIAL OTHER
OWNER' HAZARDOUS FIRE AREA
c. YES ❑ It yes-I Understand that a Class A
NAM I ��7 roof assembly is required
/ n - / NO ❑ Ir110e1 I.C.B.O.
ADDRESS - ( D OZ -2— \ �LJ/C' Z��CJ EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S C
NAME /�,� ��h TO BE REMOVED TO BE RETAINED
'ADDRESS �O l J i // {� TYPE OF ROOF COVERING
CITU 8 ZIP—
PHONE
IP PHONE -UP ROOF ❑ '
LICENSE ❑
NUMBER ASPH IN LES
LICENSED CONTRACTORS DECLARATION
I hereby affirm het I and licensed under provitdoes d Chapter 9(cemadencing with Section WOOD SHA
7000)of DNisbn 3 of the Business aha Professions Code,and my license Is In full cares antl.
effect. WOOD SHINGLES
Ucenae Close Uc.Number ❑
Date Contractor TJHE ECIFY) ❑
OWNER-BUILDER DECLARATION
I hereby affirm that I em exempt from the Contractors License Lew for the lel reason.
(Sac.7031.5,Buslne..and Proleenlons Code: Any city or county which require permI�tp, '1
corsVud,eller,Improve,demolish,or repair any structure,prior m Ito usuene.,a Ire AuG 1 _ OOF ❑
epple,Mt for such permit to file a signed statement that he is licensed pursuant to meal
of the
Convectors Ucenee Law(Chapter 9(wmmencinp with Section 7000)d O n 3 of It*
Buelness end Profe.sionm Codi)or that he is exempt Iherehom end the beads a alleged ASPHALT INGLES Elexemption.Any violated of Section 7031.5 by any applicant for a permh subjects heLf,',',7,,5kant to
a cht;penalty of nal more hen five hundred dollars(5500).1: D SHAKES
1 :3
❑I,as owner of the property,or my employees with wages se their ode com bo ns6tlea.-ywIREG'J'-
the work,antl tbe structure Is not Intended or offered for sale(Sar.7040,Business entl Parties-
sleds Code: The Contractor'.UcMsa Law does not apply to an owner of property who Wilde or WOOD SHINGLES
evElImproves thereon,and who does such work himself or through his awn employees,provided het
such Improvements are not Intended or offered for sale,ll,however,the buldlnp or Impreemeni
Is sold within one year of completion,the owner-Wilder will have the Widen of proving that he dol OTHER(SPECIFY) ❑
not WIId or Improve for purpose of eels.).
❑I,as owner at the property,am excluslvey contracting court licensed contractors to conetrvci
ha project(Sec.7044.Buakmm end Professkam Code:The Conlrecimr.LIcen.e law tloea rout PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who Wads or Improves hereon,and who contracts ler such projects
with a contrectods)licensed Pursuant to the Convector.License Law. PROVIDE MFGR.INSTALLATION SPECS.
Q I am exempt u W er Sec. ,B 8 P.C.for thus reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of he folewing decluffel :'
❑I have and will maintain a Certificate of Consent to sed-Insure for Workers Componeelbn, ' Buildin
he g
ea provided for by Section 3700 of Labor Coda,ler he perlormanwork le
ce of he wor which this 0
permit Is Issued. —'
❑I hese and will maintain Workers Compensation Insurance,as required by Section 3700 of Seismic
the Labor Code,for he pedormence of the work ler which tuts Permit In Is.ued.My Workers
Coerpensetlon Insurance canter end Policy number are: - Total
Carder Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURr one 100)N.Cor
(This section need not be completed It tha pandit Ie ler one hundred tldlem(§100)«lase.) � !/
I ceNty that In the performance of the work for which thin permit Is dsauec,I shell rot employ
any person In any manner ao as to become subject to dra Workarr Compensation Lewy of Call- All roofs shall be inspected prior to any roofing material being
forma. 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: If,after making hie CenIDcate of Exemption,you should become ,applicant understands and will comply with all non point
Subject to the Workers'Compannalbn pprovlalen$of he Labor Code,you must forthwith coney
Men such provisions or his permh chalk be deemed rewked. Source regulations.
I tartly hat 1 hers read this application and state that the seem Inf«matlon Is coder.I agree
to campy with all dry and county ordinances antl$rate leve relatlng to building cormvuddon,end All roof coveringslo be cls rbetter.
hereby authorize representathes of this city to enter upon he alkc�menibned property for In-
spection purposes.
(We)agree to saws, Indemnity and keep harmless the City of Cupertino against dadlltles,
Judgments,coats and expenses which may In any way accrue against Bald Cly In consequence
.1 the grentlngofthis permb. SIGNATURE OF APPLICANT DATE
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 "