R-6254 PERMIT R .6 2rJ 4
APPLICATION FOR,i CITY OF CUPERTINO 'I NUMBER
_ +. INSPECTION DIVISION' PERMIT EXPIRAnON - -
' 'REROOF PERMIT '(4DB).777-3225 PERMIT EXPIRES IF WORK IS NOT-STARTED.?"
".WITHIN,180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION- '
BUILDING ADDRESS 7 --
RESIDENTIAL COMMERCIAL OTHER
OWNER's a HAZARDOUS FIRE AREA
� L YES_❑ If yes-I unde stand that a Class A
NAME- • 1-r(1l T`� V U I�I,Q/L�d roof assembly Is required
• / .. NO, El Inlhal .I C B O.# '.
ADDRESS J-sy,• t -- !.I•c ����y _ ;pEXISTING ROOF COVERING r
' //-- - NUMBER OFEXISTINCOV G ERINGS
PHONE �U SctV 'te r .
` fy'� 0 - TO BE REMOVED - �. TO BE RETAINED .' .
NAME •CON 7;
TRtp W'S'
� I r l' ,dU HALL
gboREss O TYPE OF ROOF COVERING
CITY&ZIP �3 `S' �' �?�• EXISTING ,
PHONE' ,(1114l�f� 97/'_ 7Y••Z�" ;-. -. BUILT-UP ROOFLICENSE
... "..❑ .
NUMBER —/ ? z� !G _ r
ASPHALT SHINGLES ❑
--LICENSED CONTRACTORS DECLARATION -
I hereby affirm that.I am licensed untlerprovisions of Chapter 9(commencing with Section WOOD SHADES OU
7000)of Division 3 of the Business and Professions Code,and my license is In full force and r1
effect. - -
WOOD SHINGLES ,❑
License Class • - Lia Number�•� —- /J • - -
Date ` �� Contractor �ai OTHER(SPECIFY) El
License
DECL ATION -•PROPOSED '
' I hereby affirm that I am exempt from the Contractor's License Law for the following reason..
(Sec.7031.5,Business and Professions Cotler Any'city,or county which requires a permit to
construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the. BUILT UP ROOF - '❑ . .
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions _ ,
of the Contractor's.License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
•; Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
- e civil penalty of not more than five hundred dollars($500).): 1aI�� rte,.,�,�� s ❑
' e wL as and
owner osthe structure
i not i tendemy amd or or sale sJG�;.= will tloy-- tl�UtlL,IU�IU
the work,antl[he structure is net intended or of gr for sale @q 7044,Bugisese en�7t Pr`fea
sons Code:The Contractor's License Law doe Rt pply to nn r of pro ty wh iI -Z
WOOD SHI GLE$ -
improves thereon,and who does such work him 411Q into his ea l s,pro that .❑
such improvements are not Intentla or offeretl �yhap e.If,however,the building or im o ant.
the owner ? r will have the burden of proving a did- OTHER(SPECIFY) .❑ -
.not build or Improve for purpose of sale.). ��� 1��0 t -
'I]I,as eventual the property,am exclusively teach d Iic as co 6a sist truct
the project(Sec.7044,Business and Professio ode:The Contractor's Ucense La not 'PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or lmpr ves thereon;and who contracts for so r 'ects '
with a contractor(s)licensed pursuant to the C t ctor's License Law. - PROVIDE MFGR.INSTALLATION SPECS.
'❑1'am exempt untler Sec. B&P.C.for this r sen
ower Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I heretiy affirm under penalty of perjury one of the following declaration: -
El I have and will maintain a Certificate of Canaanite self-insure for Worker's Compensation, - Building/as provided for by Section 3700 of the LaborCode,farina performanceof the work for which thisOr,
permit is issued. 5�w -- seismic
El I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit is issued.My Workers - ` _ Total- /0 6o
'Compens��ejt'o` I-n�s1u a�nte terrier antl P licy number are:
carder'y�r Policy No.
PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION.FROM WORKERS' -
COMPENSATION INSURANCE N.C.
(Thissedtlon need not be completetl if the permit Is for one hundred dollars($100)or lase.) '( 2
I certify that in the performance of the work for whichthispermit Is Issued,I shall not employ
' any person In any manner so as to become subject to the Workers'Compensation Laws of Call- All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Do te' Q�/� Applicant � � �--- inspection I agree to remove all new materials for inspection.
Non ETO AP LICANT: If,after making th1 certificate of Exemption,you should becomt - A Ilcant understands and.will,comply with all non erns
sublets td the Warkers'Compensation'provlslons of the Labor Code,you must forthwith comply pp p
with such provisions or this permit shall be deemed revoked. _ ' Source regulations.
I certify that I have read this application and state that the above Information is correct)agree ,
to comply with all city and county ordinances and state lows relating to building construction,and All roof coverings to be Clasr better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
appurposes.' - -
(We) 1, TC�,J`•'/ 7
•' -(We)agree tos save,indemnify and keep harmless the City ai Cupertino y F.con liabilities,
judgments,gran costa and expenses which may In anyway accrue against geld Clry Inconsequence- SI�.INAT.URE OF APPLICANT
of the granting of this permit.
PRE-INSPECTION: ' PLYWOOD: v IN-PROGRESS:
INSP. DATE - 'INSP. DATE INSP. DATE''
TEAR OFF INSPECTION: iBATTENS: , FINAL:
INSP.' + DATE INSP. - DATE INSP. DATE
NOTE: .OSHA'APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION.
" • '- - OFFICE COPY - ' -