R-6225 PERMIT R- 6225
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION, PERMIT EXPIRATION
REROOF PERMIT
(408)777-8228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S / HAZARDOUS FIRE AREA
/,�/ YES ❑ If yes-I understand that a ClassA
NAME ! I r�asserrd*is required.
NO
Initi LC.B.O.N
ADDRESS �b SZOk S EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTORS
NAME dl Y -S TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING ,
CITYBZlp SaO3 I✓U yc!/D�(xJt9/Q/li/`L /�/ -
�{ EXISTING '
PHONE v� / �70 BUILT-UP ROOF ❑
LICENSE ASPHALT SHINGLES ❑
NUMBER C% /
LICENSED CONTRACTORS DECLAAATgN
I hereby affirm that I am licensed under provlsbne of Chapter 0(canmendrg with Section WOOD SHAKES
7000)of Division 3 of Me Business and Professions Code,and my license le In lull force and
enact' Q WOOD SHINGLES ❑
Ucense Clans �— Lk.Number
Date convector OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Conlole tra License Lew for the tong leg lesson.
(Sec.7031.5,Business and Professions Code: Any city ar county which require,a pamYt to
construct,alter,improve,dembilsh,or repair any structure,prior to its Issuance,also requlrse the BUILT-UP ROOF
applicant for each permit to file a signed statement Nat he Is naensed pursuant to the provleloas
of the Contractors License Law(Chapter O(commencJag wind Section 7000)of Dlvlslon 3 of me.
Business and Professions Code)or that he Ie exempt therefrom and the beets for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not mare than five hundred dollars
❑I,as owner of the property,or my employees with wages as their sob compensation,win do WOOD SHAKES
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Profee- G-!�
sloes Code:The Contractors License Law does not apply to an Owner of property who bullae or - WOOD SHINGLES ❑
Improves thereen,antl who does each work hlmeeff or through his sum employees,provided that
such Improvements are Trot intended or offered for We.It,fnweveh the Wilding or Improvement
Is sold within one year of completion,Ne owner-Wilder will have the burden of proving that he did OTHER(SPECIFY) ❑
not Wild or Improve for purpose of sale.).
❑I,as Owner of the property,am exclusively contracting with licensed contractors to construct
me project(Sae 7044,Business and Profeselons Code:The Contractors License Law,does rot PROVIDE I.C.B.O. REPORT NO.
appy to an owner of propend who builds a improves thereon,and who contracts,for such projects
vital a contrectoga)rbensed pursuant to the Contractors License Law. TVIBE
TALLATION SPECS:
ElI em exempt under Sec. ,BSP.C.for this reason
owner _ Dale - P -{CA N DATE ALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
hereby and under penally of perjury one n the IolbMrg declaration: ''�-7
❑ have and will malnl37 a Cehe Lab of Consent to epelormre for Workers Compensation.hicks 11CICl7/, Building
are mitprovided for by Section 3700 o1 line Labor Code,bribe pedormsnce of ft work for which this //`o
Permit a issued.
❑I he"and will maintain Worker's Compensation Insurance,as required by Section 3700 of Seismic b
_the Labor Code,for the pedormance of the work for which this Permit is issued.My WDnkere
Compensation Insurance carder aaddPPolicynumber are: /) y Total 167, 160
Carder li' r�' r a�0 Policy No. a D 3'-l71 3 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTON FROM WORKERS'-
' COMPENSATION INSURANCE N.C.0 _
(This section need not be completed If the permit Is for one hundred dollars($100)or baa.)
I cenity that In the performs cd,of the work for which this permit Is Issued,I shell not employ
anyNpa'zc'
In mannc aro as to become sublea m the workers Com nsatbn Laws,of call- All roofs shall be inspected prior to any roofing material being
1 a - installed. It a roof is installed without first obtaining an
Dat � Applbam inspection,I agree to remove all new materials for inspection.
APP CANT: II,Ona making certificate of Exemption,yo DOld become Applicant understands and will cos I with all non Int'
subject to t e Workers'Compensation prowl of the Labor Code,you mu lorthwlnd cornply PP P Y PO
with such provisions or this permit shalP'W lamed revoked. source regulations.
I cardy that I have read this applicapon and state met the above InlormallonIs correcr.I agree
to comply whin all cry and county orcilnences and state laws relating to Wlldlrg construction,and AI r f coverings to be class or better.
hereby authorize representatives of this city to enter upon the above-medtlaned property for In-
spection purposes.
(We)agree to save.Indemnity and keep harmless the City of Cupertino egalnst liabilities,
judgments,nca t els expenses;
;�Ich may In any way accrue against sale Gty Inconsequence URE OF APPLICANT DATE
,E-INSPECTION: PLYWOOD: IWPROGRES
` NSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: yy�� �! BATTENS: FINAL:
INSP. DATEIv 1r INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY