R 62740
•
0
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R_ 627 4 .
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) '777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
' 1 B DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/
L UI C UP L 2 / nI
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
�y�
N SAT 7
YES ❑ If yes - I understand that a Class A
NAME e IJ '
1 C Ai L y -
roof assembly is required
NO ❑ Init. ial I.C.B.O. H
10 3'2 D ' rL . R L_/0 (L
EXISTING ROOF COVERING
ADDRESS 61J � 9 r _ (= T / ry O
PHONE Z —
NUMBER OF EXISTING COVERINGS /
TO BE REMOVEDSNA k �= S
CONTRACTOR'S 'DUNI� III V"I'I T tDUYI
NAME 6-L L N LC Nr c_ R I (r V r Tin S
TO BE RETAINED
ADDRESS
CITY &zip112-► 60"CrrtlLLow A \1
TYPE OF ROOF COVERING
EXISTING
� 77— 0"n
PHONE��I�SS
BUILT-UP ROOF ❑'
LICENSE
Z -7
NUMBER
ASPHALT SHINGLES ❑
/
LICENSED CONTRACTORS DECLARATION
hart affirm that am licensed under provisions of Chapter S (commencing with Section
WOOD SHAKES
Di
7000) of Division 3 0/ the Business and Professions Code, entl my license Is In lull lane and
In
affect.
6 15 '3 b 7
WOOD SHINGLES ❑ ��
/
License Class Lid. Number
1 f 117- I CrLE/J L( NIS R.
. OTHER (SPECIFY) ❑
Data -1-,!
OWNERContra-BUILDER
OWNER -BUILDER DECLARATION
y
I hereby that em exempt from the License Lew for the following reason.
PROPOSED O
(Sec. 703 , Bu
Business and Professions or e: Any city
Code: Any city or count' requires a permit to
Iwhichssue
alt
applicant alter, Improve, rep prior to Its Issuance, alsorequiresthe
BUILT-UP ROOF ❑
to file siorrepeatenyetructura,
applicant for such permit to Ill. a signed statement tnci h Is licensed pursuant to the provisions
of the License Lew (Chapter B (commencing with Section Division 3 of the
/
t7000) he bast
Business entl
ss and Code) or the. h Is exempt therefrom and the Deese for the
ASPHALT SHINGLES 0/
a t0
ex Any o
violation f
of healon 7031.5 by any applicant for a permit subjects the applicant to
applicant
civil pen.
e dull penalty pl not mare Then live hu
f t more
❑I,asowneroltheproperty,ormy yso$wl esasthe�f5olecom an alion,willdo
the work, and the structure is not In.en r offaraE.(¢r%61e (Sec. pg44, Bu and Profs.
WOOD SHAKES ❑
slons Code: The Contractor's License Des n poly\den ow of pro he builds or
Improved thereon, and who does such 11 'oil or through in own ampto provided that
WOOD SHINGLES ❑
such Improvements are not Intended o ff etl I . If however, the build g Improvement
Ia sold within one year of completion,t wnar r l �wIfa2 thgpkltpgn o r ng that he dao
OTHER
(SPECIFY)
not build or Improve for purpose of sal IJJO
❑
❑ I, as owner of the property, am a lively contracting with licensed con ato construct
the project (Sec. 7044, Business and rolesslons Code: The Contractor's LI Law does not
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who bull aproves thereon, and who con tracts l such projects
'
with a contractor(s) licensed pursuan t.WtYppy�pp170nlfBG(p[b License Law.
❑1amexempt under See, or this reason
PROVIDE MFGR. INSTALLATION SPECS.
owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ I have and will maintain a Certiflcato of Consent to self -Insure for Worker's CompNeallon,
7
as provided Corby Section 3700 of the Labor Code, for the performance of the work for which tole
permit Is Issued.
1/ [-;I �
/ L O
6
Building/(
7 �
rl neva and will maintain Worker's Compensation Insurance, as required by Sactlon 3700 0l
V (/
I
Seismic
the Labor Code, for the performance of the work for which this permit Is Issued. My Workers
Compensation Insurance carrier and Policy number
Total '117, O
are: Q Tr V N 1'r
camelSTA?L F`vN0 Policy No -Lt ?06 ?061311
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.op
(This section need not be completed 11 Ne permit Is (or one hundred dollars ($100) or less.)
I certify that In the performance of the work for which this permit Is Issued, I shall not employ
All roofs shall be inspected prior to any roofing material being
any person in any manner so as to become subject.o me workers' Compensation Laws of Cali.
fornia,
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
subject to theT CE OWorrkerss' Compensation provaANT: It. after lonis ofethef1Late of borr Code, Exemption
oiu mustuforthwlithbecome
comply
Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked.
source regulations.
I certify that I have read this application and slate that the above Information is correct. I agree
to comply with all city and county ordinances and state laws relating to building construction, and
All roof COVrings to be alas or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
(We) agree to save, indemnity and keep harmless the City of Cupertino against liabilities,
'
judgments, costs and expenses which may In any way accrue against said Clty In consequence
of the granting of this permit.
lqATUREf OF APPLICANT DAT—
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