R-6393 PER"'
APPLICATION FOR CITY of cuPERTwo NUMBER R"
INSPECTION.DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORT(IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
'
BUILDING
/-ADDRESS
311 ( -`"(L, /�C.I� RESIDENTIAL COMMERCIAL OTHER
OWNER'S GST - �� HAZARDOUS FIRE AAREA
YES I1 yess Imblyi req Mat. ClassA
NAME ry�t
assembly is regWnetl.
ADDRESS z Z3l/ r/�L �`` �'•ib`�' EXISTING ROOF COVERING
PHONE 6 NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S ��,{r /�♦f
TO BE REMOVED TO BE RETAINED
NAME ! O
ADDRESS TYPE OF ROOF COVERING
CrrVBZIP
A EXISTING
PHONE 3�` BUILT-UP ROOF .
LICENSE
NUMBER 3 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby sion that em licensed and
Pr Rove rre of Chapter p(coma eis In with Section WOOD SHAKES ❑
]000) r DMsian 3 al the tic neer entl under
provision
io of C,and r 9 license b In lull lone and ,
site J
License C4. Lb.Number f���AY/ �^ L� 00 I ❑
Dale l Z7 <� Contractor C_'�"�iC OTHER(S ECI ) ❑
OWNER-BUILDER DECLARATION affirmPR D 7199
I hereby arm that I am exempt from the Contractor's License Law for the fallowing reason. 9
(Sec.7031.5,Business and,Profesebns Code: Any city or county which requires a permit to
construct,alter,Imve
pro ,dampish,or repair any structure,prior to Its lewence,also requlres the B BUILT-UP ROOF ❑
applicant for such permit to me a signed statement that he Ls licensed pursuant to the provisions Y
of me Contractor's Llcenso Law(Chapter 8(commeac with Section]000)of DMsbn 3 W the
Buslness and Professions Code)or that he is exempt therefrom entl me basis for the alleged! AS S
exemption.Any violation of Section 7031.5 by any applicant for a permlt subjects the applicant to
a civil Penalty of not more than flue huMret dollars($MD).):
❑1,as owner of theproperty,or my employees with wages as their able compensation,will do WOOD SHAKES ❑
the work and the structure is rot Intended or offered lar able(Sec.70",Business and Profes-
alore Code:The. enactors License Law does nut apply to en owner of property who Iwlkb or WOOD SHINGLES El thereon,are who does such work himself or through his own employees,proOdetl that
such improwmenta are not Intended or offered for sale.If,however,the building or Improvement
Is sold within one year of completion,the miner-bullder will have the burden of proving that ha tlb OTHER(SPECIFY) ❑
net bulltl or Improve for purpose of sale.).
.❑1,as owner of toy property,am exclusively contracting with licensed contractors to construct
trio project(sac.7044,Business and Professions Code:The Contractors License Law does rot PROVIDE I.C.B.O.REPORT NO. -
apply to an owner of property who builds or Improvoe thereon,soy who contracts for such phi
with a ockarWor(s)licensed pursuent to the Contractors License Law. PROVIDE Vill INSTALLATION SPECS.
❑I am exempt under Sec. ,B-&P C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION s
I hereby affirm under penalty of perjury one of the fogoMng declension:
❑1 have and will malmen a Certificate of Car l to sefiinsree for Workers Compensation, Building f
as provlded for by Section 3700 of the Labor Code,for the performance of the work for which this ��O
permit is issued. j`J\ SeISmIC - S�
I-1 I have and will maintain Workers Compensation Insurance,be required by Section 37DD of .
the-Labor Cada,for the performance of the work for which this parrot a full My Workers
-Compensati�onf'I,n�sufr�ance carrier entl Pal number ere: Total ! 7x
Cenlar_ (M Policy No. 13Y1 " PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
Mbn'III not be completed If the pearl for one hundred dollars(5100)or less.)
I co bty that in the Performance,of the work for which this permit Is anal I Mall not amp"
(This e
any person In any meaner so as to become subject to the Workers'Compensation Laws of Ceti- All roofs shall be inspected prior to any roofing material being
fmnla. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensellon provisions of the Labor Codo,you must forthwith carply,
with such provisions or this permit sha ttee deemed revoked. Source regulations.
I cerdfy that l have read this epplkal on aM stela met the above Information is conect.l agree
to comply with all city and county ordinances and state Aare relating to building constructlon,and All roof coverings to be class or better.
'hereby authorize re treamea ves of this city to enter upon the above-mentioned property for In-
apportion purposes.
(We)egos to aeve,Indemnlfy.and keep harmless ma,Gty of Cupertino against IIMWties.
i
Judgments,
f M granting of 1Niv expenses
which they In any way accrue against sale City,Iconsequence ATURE 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY