R 6202•
t
0
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R. 6202 .
' INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 - PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
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031/ 96A4 %� OwI4%c
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RESIDENTIAL COMMERCIAL OTHER
OWNER'S '/��HAZARDOUS
FIRE AREA
yes — I understand that Class A
YES Imoof
NAME— �L/I��YJ/� !�L LD ±!Zo
assembly s required.f
NO ❑ Initial I.C.B.O. q
/03i/ L1Jl�ws'D�
- EXISTING ROOF COVERING,
ADDRESS �.Y/cJ�'.
,
PHONE ZSi— S
NUMBER OF EXISTING COVERINGS
CONTRACT/O9/Ff/
j�/L/✓ii. Ai�•,r
TO BE REMOVED TO BE RETAINED- C/
NAME cJ tGU�l�71s
�
ADDRESS /�
TYPE OF ROOF COVERING
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CITY 8 ZIP /�/ -J • L-3�JYy�'%b �
EXISTING .
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PHONE �_/1T S�/ /DYJ
❑ ,
BUILT-UP ROOFLICE
NUMBEa
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 0 (commencing with Section
WOOD SHAKES
7000) of Division 3 of the Business and Professions Code, and my license is In lull force and
effect.
3
WOOD SHINGLES ❑
License Cissa Lid.N
Lc. Numbe/rJ��
�
Data 0GLjL L(d
OTHER (SPECIFY) ❑
OWNER -BUILDER DECLARATION
hereby affirm that am exempt from the Contractor's License Lew the ng reason.
70315,
PROPOSED �s
wforhich
(Sec. Business and Professions or Code: Any city or or requires
wNah re,
e permit toconst
V
rep to It also
prior tolls Issuance,alsoeprovi
BUILT-UP ROOF ❑
pplic nt,orsuchpermittofile signeepakeny menthatstructure,
applicantfor such permit Ills a signed that he Is licensed pursuant to the provisions
provisions
of the o License
of the Contractor'ssennaLew (Chapter B (commencing with Section 7000) of Division
r 9 (co m
3 of theBusine
�+
and Code) or that he is exempt therefrom and the basis for the
he
ASPHALT SHINGLES ❑ `�
exempss
violation of
exemption. Anyf violation of Section by any sppllcsnt for a permit subjects the applicant to
applicant to
pen.
more
e civil penalty of not mora than live hundred ($500).):),I:
than hundred
❑I, as owner of the property. or my employeesyees withw tion, will do
OD SHAKES
the work, end the structure Is not mien 4, Bus and Profes-
sions Code: The Contractor's License L e6 not en owner xf prop he bulltls or
Improves thereon, and who does such w sell hie ow mploy ovided that
WOOD SHINGLES ❑
such Improvements are not Intended or 1 r for se e. IL however, the bulltlin o provament
Iseoldwlthmoneyearofcompledon,the -bu(il�der will have the b 1 thethe did
1• i ,
`({ 0
v
not❑b improve torp u� Darya of ealof
c
OTHER (SPECIFY)
1, as y ralra�9I
I, as owner of the pro er em axcl cohk66EEtlh h en ohim oconstruct
���( O
the project (Sec. 7044, Business and Pr some Code: The Contractor's Los does not
epplytoanownerof property who builds proves thereon, and who contracts for s hprojects
PROVIDE I.C.B.O. REPORT NO.
with a contractor(s) licensed pursuant to a Contractor's License Law.
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 am exempt under Sec. Is reason
Owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
1 hereby affirm under penalty of perjury one of the following declaration:
❑ 1 have and will maintain a Certificate of Consent to sell -insure for Worker's Compensation,
/
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
/ p
Building
g.
permitle issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
seismic
the Labor code, for the performance of the work for which this permit is Issued. My Worker's
-
/_5
Compensation Insurance carrier and Policy number are:
Total =00
Carrier S,J 7P LyNO Policy No. /973 7 93 '16
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
-TO
^�
COMPENSATION INSURANCE 100) o
(This section need not be completed II the permit Is for one hundred dollars ($100) or lase.)
I certify that In the performance of the work for which thio p Ill lasued, I shall not employ
All roofs shall be Insp cted prior to any roofing material being
installed. If a roof is installed without first obtaining an
Zany
any person In any armor so as to become subject to the ensatlon Laws of Cell-
fornia.
Date AppBort
inspection, I agree to remove all new materials for inspection.
aubjaia the WOon TO PkersCCompeneebon proNellhie iecome
tpallot ExerCodemyou mtion ust forthwithcomplyApplicant
understands and will comply with all non point
with such provisions or this permit shall b ed r d.
source regulations. -
certify that I have read this eppllce ntl state ei fhe above Information Is correct. agree
to complywith ellclryentlounryord' noes and stets laws relating to building constructlan,antl
All roof cove i' s eclass"C"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 a ainst Ilabilltles,
judgments, costs and expenses which may In any way accrue against said City n consequence
SIGNAKEOK APPLICANT
Dl magranlingolthispermit.
DAT
PRE -INSPECTION:
PLYWOOD:
IN -PROGRESS:
INSP. DATE
4001r
ef
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