R-6503 „
.r
PERMrr
APPLICATION FOR CITY of CUPERTINO NUMBER R” 6503
INSPECTION DIVISION PERMIT EXPIRAT1, N
REROOFPERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS -
TE LL(N G - RESIDENTIAL COMMERCIAL OTHER
OWNER'S _ HAZARDOUS FIRE AREA
/j�7 / K VES ❑ II yes—I wlderetard that a Class A
NAME +-�y1 �`� ' `�T ,{ roof essernbty is required.
(0 3 r U �f. 0,wk _ NO �,y Initial I.C.B.G.R
ADDRESS- 1 p- EXISTING ROOF COVERING
PHONE BU �� NUMBER OF EXISTING COVERINGS O�
CONTRACTOR' '
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP ,
EXISTING
PHONE BUILT-UP ROOF El
LICENSE
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I.hereby efhnm that I an,licensee under provlslms of Chapter 9(comanencing with Section WOOD SHAKES
7000)of DNlalon 3 of the Business and Professions Code,entl my license Is In lull force and
effect. - WOOD SHINGLES (
License Class Uc.Number J
Date cmtram« OTHER(SPECIFY) ❑
OWNER-BUIIDERDECIARATION I PANT 199
I hereby anlnn that I am exempt from the Contractors License taw for the following reason. PROPOSED t
(Sec.7031.5,Business end Profession*Code: Any dry or county which requires a permit to
construct,eller,Improve,demolleh,or repalr any structure,prior to its issuance,also requires the BUILT-UP ROOF By Elapplicant for such permit to fie a agnea statement that he Is licensed purau rtu to the provisions
Of Ne Convectors License Lew(Chapter B(corrvnenclrg with Section 7000)of DNlslon 3 of the
• Business and Professions Code)Or het he is exempt therefrom and the beefs for the alleged ASPHALT SHINGLES
exemption.Arty voletlon of Section 7031.5 by any applkent for a permit subjects the applicant to
e dull pe try Ils
of not more than e hundred*clam($500).): WOAD SHAKES
�m owner of the property,or my employees with wages as,their ode compeneetlon,will do ❑
Me work,and the structure le not Intended or allered for sale(Sec.7041,Business ane Profen-
. alms Code:The ContmOore Ucenee Law does not appy to an owner of property wino bullas or WOOD SHINGLES
Improves therom,and wbo does such work himself or through his awn employees,provded that ❑
such Impro menta are not Intended or offered for sale.If,howaver,the bulking or Improvement
is sok w1min one year of complellon,the owner-Iwllder win have the burden of prodng that he did OTHER(SPECIFY) ❑
not Wild or Improve for purpose of ssleJ:
❑I,as owner of the property,em exclueWely contracting with licensed contractors to conatnld
the project(Sec.7044,Buslness and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
appy to an owner of property who builds or Improves thereon,and who contracts for such projects
with a com )Il�en pursuant to me cmtrectolx
ra ense law. PROVIDE MFGR.INSTALLATION SPECS.
❑I em wexomptempt Se or Sec. ,B 8 P.C.kr this reason
N A L r
o—rf - A n e --n7 APPLICATION DATE VALUATION PERMIT FEE
R SATION DECLARATION7n
I hereby affirm uncler penalty of perjury one of the folkmtrg declaration:
1 have and will maintain a Certificate of Consent to setl-lnsure for Workers Compensation, Building
m provided for by Secdw 3700 of the Labor Cade,for the performance of the work for which this �J(��
permit Is Issued.
ave , S�
❑1 hentl will maintain Worker's Compensation Inau lance,as required by Sactjon 37W of Seismic
the Lobar Code,for the Performance of the work for which this permit Is Issued,My Workers `7 l--T•
Compensation insurance carrier and Policy number ere: Total
Corder Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ ^ _
(This section need net W Completed It the pernJt Is for one hundred adieus(f100)«ben.)
I curtly that In me performance of the vrork for which due pemst at issued!,Ishell r- empicy
arty person In arty manner w as W cecc me subject to me Workers'Compensation Leve d Co0. All roofs shall be inspected prior to any roofing material being
Wmfo. 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 this Certificate of Exemptkh,you should become Applicant understands and will comply with all non int
subject to me Workers'Compeneatbn provisfons of the Labor Code,you must lorhwim campy pP P Y PO
with such provisicns or this Permit BhalCbe deemed rewked. source regulations.
I certHy hal I have read Mle eppilcation and state mel the above Information Is correct.I agree
to compy,with an dry and county ordinances and state laws mating to Wading coosmxbon,end _ All ro overings to be clasor better.
hereby euhodze representavves of this city to enter upon the above-mentkxrod property for In. ^—
epectbn Wrposes.
(We)agree to rune,Indemnity,entl keep harmless he City of Cupertino against Ilabillbes, �ICANT'otlpmento,costs and expenses,which may In any way accrue against oak Clry In conseWance T RE OF DATE
of IBa granting of this permit.
• 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