R-6532PERMrr R_
APPLICATION -FOR CITY of CUPERTINO NUMBER 6532.
INSPECTION DIVISION PERMIT EXPIRAnN
REROOF PERMIT (408) 7773M PERMIT EXPIRES IF WORK IS NOT STARTED '
WIT -HN DAYS PERMIT ISSUANCE O
180
1 DAYSS FROM LAST FCALLED INSPECTION..
BUILDING ADDRESS
RESIDENTIAL COMMERCIALOTHER
OWNER'S HAZARDOUS FIRE AREA
N VES ❑ If yes— I understand It Class A
NAME_ �—S\l �ilJ roof assembly is requlled.
NO Ifl-_ InNel I.C.B.O. P
ADDRESS j J
CITY & ZIP
PHONE1�b
I hereby affirm that I am licensed unser provlelom of Chapter a (carrmerdng with Section -
7000) of DMsIw 3 of the Buslnaes and Professions Code, and my`lliiccann�e)sb In lull so" and
Lkonse ea Uc. Number
Date Contredor"^'1 �^��
OWTIER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec. 7031.5, Business entl Profe shone Code: Any dry or county which requires a permit to
caaatr , after, Improve, damollsh, or ropelr any structure, pdor to Its Issuance, also requires the
applicant for such permh to file a signed statement that he Is Ilcensed pursuant to the provolone
of the Contractors License Lew (Chapter g (commendng with Settlor 7000) of Dlvlelon 3 of the
Buelness and Profession Cade) or that he Is exempt therefrom and the bawls for the alleged
exemption. Arry Aouttlon of Section 7031.5 by arty applicant for a permit subject the applicant to
a GNI penelry, of not more then five hundred dollars (5500).):
I] I, as owner of me property, or my employees with wages as their We compensation, will do
the work, and the structure is mot Intended or offered for sale (Sac. 7044, Bualnesa and Profes.
alone Cade: The Contrectora License Lew does not apply to an owner of proparty who bulloa or
Improves thereon, end who does such work himself or through hue own employees, pravltlatl that
such Improvements are not Intended or offered for sale. If, however, the bulldlrq or Improvement
Is sold W MIn we year of completion, tie owner -builder will have the burden of proving that he did
not build or Improve for purpose of Bele.).
❑ I, as owner of the property, am exclusively contracting with Iioanad contractors to caetnwt
me project (Sec. 7044, Business and Professions Code: The Contractors I -ceps, Lew does wt
appy to an ownar of property who builds or Improves thereon, and who contracts for such projects
with a cantector(e) licensed pursuant to me Contractors Dcene Law.
❑ 1 am exempt under Sec. ,B & P. C. for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION '
I hereby off under penalty of perjury ane of the following declaration:
❑ 1 hale and will maintain a Ceniticete of Consent to self -Insure for Workers Compeneatlon,
as proNded for by Section 37DO of the labor Code, for the perlormarwe of the work for which this
permit Imuad.
Zhave and will maintain Workers Carpensetlon Inre
unce, as required by Section 3700 of
I Cotle. for me porformance of the work for which this permit Is lesued. My Workers
Copeneon nce c� lley nuroer are:
Carrier
s
PGIcy No. \\
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(Thin section need not nd completed 19* parmit Is for one hundred ddlam (f IDO) or lees.)
I tartly that In int performance of the work for which this Permit Is issued, I shall not employ
any person In any manner so u to become sub** to the Workers' Compenaetlon I-aws of Cello
forme.
Date Applicant
NOTICE TO APPLICANT: It, after making this Certlficete of Exemption, you should become
subject to the Worker' Compensation provislons of the Labor Cade, you must forthwith comply
with atkM proNsion, or mus permit shell be deemed revoked.
I candy that I have reed MIS awlicatlon end state that the alcove Information Is c Tact I agree
to comply with all city and county ordinances and state laws relating to bullding contructbn, and
hereby eulhorlxe representatives of this dry to enter upon the above-mentioned property for In-
spection purposes.
(We) agree to save, IrMemnity and keep harmbss the City of Cupenlrw ap.Inst IIebllitbs,
WOpmanb, costs and expenses which may In any way accrue against said Cly In consequence
of tFe arent)" of this permit.
NUMBER OF EXISTING COVERINGS
TO BE
EXISTING
BUILT-UP ROOF
ASPHALT SHINC
WOOD SHAKES
WOOD SHINGLE
OTHER (SPECIF
BUILT-UP ROOF
TO BE RETAINED
me
MAY 0 ED
' jqq(
ASPHALT SHINGLES
❑
WOOD SHAKES
Q
WOOD SHINGLES-
❑
OTHER (SPECIFY)
❑
PROVIDE I.C.B.O. REPORT NO.
PROVIDE MFGR. INSTALLATION SPECS.
APPLICATION DATE1 VALUATION I PERMIT FEE
J Buildjv�3 7
v Seismic p O
Total
I PERMIT AUTHORIZATION I DATE I
All roofs shall be inspected prior to any roofing material being
installed. If a roof is installed without first obtaining an
inspection, I agree to remove all new materials for inspection.
Applicant understands and will comply with all non point
Source regulations.
Al� kof coverings to be class or better.N
PRE -INSPECTION: PLYWOOD: PROGRE10
INSP, DATE INSP. DATE INSP. - DATE
TEAR OFF INSPECTION: I BATTENS: I FINAL-
NOTE:
INAL
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION