R-6401 j PERMIT
APPLICATION FOR CITY of CUPERTINO NUMBER R-. 6401
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PER/AIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
lA 180 DAYS FROM LAST CALLED INSPECTION.
BUILDI;G11`` �bAPDR'lS V I S TC1 C V
�Ull Cf- �`�� RESIDENTIAL-,ZZCOMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
S ,MCS4 r{( erA, cJ YES ❑ If yes-I tmG
derstand that a assA
NAME l l 1 `1 L rodassembly is required.
ff ( NO IrMlat I.C.B.O.N
ADDRESS_6 (3� . EXISTING ROOF COVERING
PHONE `l `� �L 6 NUMBER OF EXISTING COVERINGS
CONTAAC l R'S _ r
NAME'7e)W `y /`l !7 n' C i ('rG TO BE REMOVED TO BE RETAINEDy
ADDRESS TYPE OF ROOF COVERING
CITY s ZIP EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed umear provisions of Chapter g(commencing with Section WOOD SHAKES
70(10)of Dlvtebn 3 of the Business and Prolesaions Code,and my license b In full force and
effect. WOOD SHINGLES
DClose Lk.Number
Dateate ContractorOTHER(SPECIFY)
Wt from BUILDER DECLARATION PROPOSED
hereby ,Bur that em exempt from the e: Any city
License Lew for the measfoll.Ing reason.
(Sec.70315,Bullnose and Profeaskxrs Code: Any cry or county which re,also a permit to
construct,alter,Improve,d file as,or repah any structure,ptlor to its pursuant also reproves the BUILT-UP ROOF ❑
of the o for such permit to flaw a signed statement that he lehcans o7000)pursuant to the pmvblare
of the ss an Pr's Lbwnse Law(Chapter h is ex endrg etch Section the th of Dforthe 3 0l the. .
exemptio end violation of Code)or that he la exempt torebom and the heels for the scant to ASPHALT SHINGLES Q/
exemption.Anyviolationo t more
of than
fon 70315 by arty applicant for a permit subjects the applicant to
e chAl rally of not mora than Ilve hundred dollars($500).):
es owmerof the property,or my w Ioyees vnlh wages as Nelr had compensation,will do WOOD SHAKES ❑
th rid,entl the eVuclure Ie not Intended or offered for sale(Sec.7044,Business and False-
0:
The Contractor's Lbense Lew does rot apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himseff or through his own ampfoyaes,provided that ❑
such Improvements are not Intended or offered for We.ll,however,the building or Improvement
is sold wiMn oma year of completion,the cwner-bulldrr will have the burden of proving that he did OTHER(SPECIFY) El
bdld or Improve for purpose of Bele.).
❑I,m owner of the property,am exclusi contracting with licerued contractors to construct
the protect(Sm.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bullps orlmprores Narem,en who contracts for start protects
wiNa antexempt Index ec"uveue I con Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,B d P.C.for Nb reason
Owner Date
WORKER'S COMPENSATION OECLARATIQN APPLICATION DATE VALUATION PERMIT FEE
'
I hereby affirm under penalty of perjury one of Ma following tleclaretlon:
❑l have and win maintain a Certificate of Consent to ser-Insure for workers Compensation, n Building o7
as provkfed for by Sectlon 3700 of the Labor Code,for Ne performance of the work for which this �/[/ 0
permit is Issued. 1 � Seismic b
❑ have and will the pelrf Workers f the for Insurance,which
this ae repulsed M Sachin irk 0l / /
,the Labor Code,for the performance of tyre work for which Ihle perms Is leeuetl.My Workers Total / i�
Compensation Insurance carrier orb Pdlry number are:
carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WV RKERS' ^
COMPENSATION INSURANCE N.C❑
(This sactlon need not be completed r the Permit Is for one hundred cohere($1 W)or best
I candy that In the performance of the wont for which this pemdt Is lasued,I shell not employ
any person In arty manner co as to become sup to the Workers'Cori m nBatio Lawn m Cad- All roofs shall be inspected prior to any roofing material being
fornla. C'rinstalled. If a roof is installed without first obtaining an
Date 3 Z y 1 Applicant �r"�'" inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,after making this Certificate of Exemption,you Mould become
wNext to the Workers'Cornpeneetlon prowslons of the labor Code.you meet forthwith comply Applicant understands and will comply with all non Point
with such proverms or this permit ehalCo seemed revoked, source regulations.
I coNty Net l have read this application and state that the above Information is correct.)agree �yI
to comply with all city and county,ortllnances and elate leve relating to butiding corretruc8on,antl rya roof cover.ngs to be class better.
hereby strophe representatives d this,airy to anter upon Ne ebwe mentloned property for In- ��' _ C? 2
Mpection purposes. �/()
(We)agree to save,Indemnify and keep harmless Ne City of Cupertino against IIabllWes,
Judgments.coats and expenses which may In any way accrue against said Clry In co sepuwrne SIGNATURE OF APPLICANT DATE
OF APPLICANT DTE
of Ne granting of thio permlL
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