R 6337•
' OFFICE COPY
NUMBER R- 6337
APPLICATION FOR CITY of cuPeRrlNo
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
1 BUILDING ADDRESS
C /.-y,
/O Z,/o? ? 4,1V S�_Il
O /,10wF
RESIDENTIAL COMMERCIALOTHER
OWNER'S/ /7 /�
HAZARDOUS FIRE AREA
YES ElIt I ClassA
NAME "��� `/ i I/
yes- understand that a
root assembly is required.
NO ❑ Imflal I.C.B.O. A
q
2— 2% �L_
EXISTING ROOF COVERING
ADDRESS -� / Ova_
NUMBER OF EXISTING COVERINGS
PHONE 3
CONTRACTOR'
NAME
TO BE REMOVED TO BE RETAINED
ADDRESS Zfs6 �,c+ �) .-.
TYPE OF ROOF COVERING
CITY &ZIP
C44-2 op 4EXISTING
,�,'�
PHONE �� ��
BUILT-UP ROOF . ❑
LICENSE
NUMBER _;S J�2,3;,
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter S (commencing with Section
WOOD SHAKES
7000) of Division 3 of the Business and Professions Code, and mylicense is In lull force and
effect. 7 ( 0
� J 2
WOOD SHINGLES ❑
License Claes Lic. Number
Date 41,'� .^cjk contractor /�
OTHER (SPECIFY) ❑
_
OWN�,jEf ;BUILDER ®EC-RATI N.-. j
a reason.
hereby Bu tnat em if�t from tOOUR, mr,or�Llcaneni.ew for the requires
(Sec. 7031,5, ove antl aeons lsAny count which requires a permit to
ppppOSED
alter. imp Fa ure. p}
requirestheBUILT-UP
coplicant,oruch permit to I' erre aemntlthat he plicendortose Issuance, pursuant to
applicant for each permit to II nate statement that he Is licensed pursuant to the provisions
of the Contractor 'e Llcanee L at%h (c m ert�Ing�p�dl� ction 7dp0) of Division 3 of the
ROOF ❑' 72
Business antl Proleaelone C r ilial navly empt tNew�i a tl the basis im the alleges
ASPHALT SHINGLES
exemption. Any vloletlon of Se jlpn 703ASby any applicant for a per�ji't-eubjecis the applicam o,
e civil
❑
f
penalty of not more the a hundred teollare ($500).):
❑I, ae Owner of to proper r my employees with wages as theirsole ompeneation, do
WOOD SHAKES '
will
the work, and the structure ist intended or offered for sale S uslness and Prolea-
aloneCode: The Contractors c Lawd property who builds or
Improves thereon, and who doe r rough his own employees, provided that
WOOD SHINGLES ❑
such Improvements are not Inten ad or offer etl for Gale. II, however, the Wilding or Improvement
Is sold within one year of completion, the own er-bullderwIS have the burden of proving that he did
not build or Improve for purpose of sale.).
OTHER (SPECIFY) ❑
❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sec. 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 builds or Improves thereon, and who contracts for such projects
with a c pursuant tome Contrector'e License Lew.
Index
m exempt Se
I am exempt under Sac. ,B 8 P. C. for 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:
❑ 1 have and will maintain a Certificate of Consent to sell -Inure for Workers Compensation,
/
as provided for by Section 3700 of the Labor Coda, for the performance of the work for which this
permit la Issued.
// �-7 /
Building
g
❑ I have and will maintain Workers Compensation insurance, a9 required by Section 3700 0l
/� to ' / b
Seismic
the Labor Code, for the performance of the work for which this permit Is issued. My Worker's
Compensation Insurance carrier and Policy number are:
/
Total /79 30
Carrier Policy No.
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the permit IS for one hundred dollars ($100) or toss.)
I
` #
certify that In the performance of the work for hlch this permh le uetl, shell not em toy
any person In any manner so as to become sub' I to the Work
All roofs shall be inspected prior to any roofing material being
pensatlon Laws of Lull-
fornia.
r
Da10,04- /
installed. if a roof is installed without first'obtaining an
inspection,
Appll am
I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, after making this Certlli eta of Exemption, you should become
subject to the Workers' Compensation provisions 01 the Labor Code, you must forthwith comply
Applicant understands and coil Comply with all non point
pP p y p
with such provisions or this permit shalQbe deemed revoked.
Source regulations.
I certify that I have read this application and state that the above Information Is correct.I agree
n
to comply with all city and county ordinances and state laws relating to building construction, and
All Cot coverings to be class'' better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
-'&r
'
spection purposes.
(We) agree to save, Indemnify and keep harmless the City of Cupertino against liabilities,
2 �,
Judgments, costs and expenses which may In any way accrue against sale Ciry In consequence
of the granting of this permit.
SIGNAT O APPLICANT DATE
PRE -INSPECTION:
PLYWOOD:
IN -PROGRESS:
INSP. DATE
INSPDATE
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