R-6524 APPLICATION CITY OF CUPERTINO
ON FOR
C
NUMBER PERMIT
R- . 6524
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(406)777-3228 PERMIT WITHIN 180EXPIRES
DAYS OF PERMIT ISSUANCE OR
- 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS -
L ZoC�l Bc5'h�l /�� RESIDENTIAL_COMMERCIAL OTHER
OWNERS Y '. / I aHAZARDOUS FIRE AREA
NAMEy�I2 /Salk (/L YES ❑ ,rfloyo�lesnds assambly,gd ra �t a Class A
NO e/ Initial I.C.B.O.Ii
ADDRESS
7�0� cS�tO��✓ owrve EXISTING ROOF COVERING
��p� (�
PHONE Z.zO NUMBER OF EXISTING COVERINGS I
CONTRACT ---�� Gam,. - C .
NAME_ U� �f� / �y/ TO BE REMOVED TO BE RETAINED_(
ADDRESS . TYPE Gly 3'✓_. //- e TYPE OF ROOF COVERING
CITY&ZIP' Y� ^ fTy�-
EXISTING
PHONE BUILT-UP ROOF ❑
NUMBER ASPHALT SHINGLES El
LICENSED CONTRACTORS DECLARATION
I hereby afumr oft I em Ilcaneetl under Professions
of Chapter 0(cans eis In with t "Socconand WOOD SHAKES
]000)of OWlelon 3 of he Bwlmee and Proleesbne Cale,and my lienee Is In lull brae end
effect.
WOOD SHINGLES ❑
License Claes Lw.Number
Data Contractor OTHER (SPECIFY) -
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt lnan the Contractor's Lfc""Low for the following reason.
(Sec.7031.5,Business and Professions Cade: Any clry or county which requires a permlt to
construct,alter,Improve,demolish,or repair any stmcturs,prior to Its Issuance,also requires the BUILT-UP ROOF Elapplkent for such penMt to file a signed statement that he Is licensed pu rauant to the provlslone
of the Contractors Ucense Law(Chapter D(cammencing with SecLam 7000)of Division 3 of the '
• Business and Professions Code)a that he Is exempt tlrerelrom and trn basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil"many of riff more than fines hundred column($500).):
AU_an owner of the property,or my employees with wages se Moire ale compensation,will WOOD SHAKES Elew
tho"rk,and the structure fe not Intended or offered far sale(Sec.7044,Business and Profile.
None Code:The Contractors License Law does not apply to an owner of property who builds a WOOD SHINGLES
Improvas thereon,acrd who does socin work hlmseti or through his employees,
own provided that ❑
such Improvements are oat intended or offered for sale.It however,the bantling or Improvement
Is sold wimm one year of completkln,the owner-bulkier will have the burden of proving that he did OTHER(SPECIFY)SPECIFY)
not build or Improve for purpose of sale.). ❑
as owner of the property,am excluMvey contracting with licensed contractors to construct
the mlect(Sec.7044,Business and Professions Code:The Contractor's Ucense Law does not PROVIDE I.C.B.O.REPORT NO,
apply to an owner of property who builds or Improves maroon,and who contracts for such prolects
with a cormac or(s)Ilranaed purauam to the contractor's License taw. PROVIDE MFG R. INSTALLATION SPECS.
❑1 em exempt under Sec. ,B 6 P.C.for this re
OW a �a1e- APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION E IIATI0,
I hereby riffirm under penalty of penury one Of the foS5Wng de laratlon:
❑1 have end MI maintain a Certificate of Consent to self-Insure W Workers Compensation, BUIIdin
ail providetl for by Section 3700 of the Inbar Cade,for the performance of the work for which this g
Permit le Issued.
❑I have and will maintain Worker,Compensation Insurance,m required by Section 37DO of Seismic
the Labs Code,for me Performance of Me work for which MIs permit Is Issued,My Workers !!��
Compenaadon Insurance carrier and Policy number are: Total 0
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section read not be completed it the pens t Is fa one hundred dollars($100)or lees.) "
I certiy that In the performance of the w for which this Permit Is Issued,I shell not employ
any person In any manner so m to become eAm to the workers'Compensettan Laws pr'Can- All roofs shall be inspected prior to any roofing material being
fornia. X installed. If a roof is installed without first obtaining an
Date Applicant�` ��1 -Y�_ inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: ll,aft
er making ttl . mate of Exempemn.raks�,awa+eaofflr� Applicant understands and will comply,with all non point
subject to the Workers'Co ernsatlon ProvlebnrWrthe Labor Code,you must forthwith campy PP P
with such provislors or MIs perms shall be deemed reeked. source regulations.
I cant that l have react one application and state Met the above Information Is correct l agree
to comply with all dry and county ordinances and Mate laws releung to bullding canstructon,an! All roof coverings to be class or better. -
hareby author"representatives of Mfe city to enter upon the above-mentioned property for In. /—
epectionWe) purposes.
(We)agrees save, psnsss ry end keep harmless was Mduo a of against
saNrn yin con liabilities,
of Me gran coats entl expenses which may In any way accrue egsNst sed Clry In consequence
of he granting of this perms. SL@WURE OF APPLICANT DA
PRE-INSPECTION, PLYWOOD: IN-PROGRESS:
Aft 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