00050115 Z� - 3 / �- 2�o G
APPLICATION FOR ciTv oF� cuPeari o���� NUMBER��
INSPECTION DIVISION PERMIT E%PIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTEO
� WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1B0 DAVS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
1 c� ��3 t� 1��� 1-�- a�
RESIDENTIAL� COMMERCIAL OTHER
OWNER'S /'� HAZARDOUS FIRE AREA
`G 1�1 ��/T�,l�r�,+� / VES ❑ I�yes–I underetand lhat a Class A
NAME � k–���� b �r T�-ti v r�� rootassembly is required.
NO ❑ Initial I.C.B.O.N
nooRESS � C� i 33 � � �a( �I� EXISTING ROOF COVERING
PHONE O �� I NUMBER OF E%ISTING COVERINGS d�
CONTRACTOR'S (� (���/^y–�� �+.
NAME ( @ 1� �7�'��.–�� \�-/�l� .I � TO BE REMOVED `/� TO BE RETAINED
nooaesS ��^ ��� I —'7 -7 J^ 1 � PE OF ROOF COVE NG
CITY 8 ZIP � J �G._\V � EXISTING
�tCS3�3�- 1Z3�� C
�PHONE BUILT-UP ROOF �
LICENSE � � Z �� '�03i qSPHALT SHINGLES ❑ �j�
NUMBER +
� LICENSEDCONTRACTORSDECLARATION � i V
I hereby aHirm the[I em Iicense0 untlar provisions ol Chepter 9(commencing with Sectlan �WOOD SHAKES �47
1000)o�Divislon 3 0���e Business antl Prolessions Cotle,entl my Ilcense la In WII tome entl �"\
eHecL
�'` Q � WOOD SHINGLES ❑
�:?ense Class y� 1 Lic.Number- � O�� .
oete 5���� comrac�or�A�m� RC�"lA� OTHER(SPECIFY) ❑
—���R-BUILDER DECLARATION pROPOSED
I hereby effirm�het I am arempt Irom t�e Conirector's Licenso Lew br the followlnq reeson.
(Sec.�031.5,Business entl Profassians Cotle: Any clty ar counry w�ic�reQulree e parmit to
consimc6 elleq Improve,tlemollsh,or rapelr eny stmcmre,v�lorm Its Issuence,elso repulrea ihe BUILT-UP ROOF �
epplicent lor such perml�to lile a slgnoC stalement ihet�e is licanaed pursuant to�he pmvislons
o��he ConVactors Llcenae Lew(Chapler B(commeneing with Sec�ion]000)al0ivlslon 3 of Ihe
.� Business entl Profeseions Cotle)or ihe�ha is exemp�iheretrom end ihe Eesls�or�he elleged ASPHALT SHINGLES ❑
axamp�ion.Any violallon ol Section]031.5 Ey eny epPlicent for e permlt suC�ecte the eppllceN to
e civil penelty of nat mom��an ilve hunCretl tlallers($500).): �
❑I,asownBrol�hepropatly,armyemployaeswi��wapeseslheireolecompenaellon,willtlo WOODSHAKES
ihe work,entl ihe simcture is not Intentletl or oiferetl lor sale(Sec.704d,Business entl Pmtee-
sions COEe:7he Contractor's�Icense�ew doee no�appry m en ownero�properry w�o bul�Es or .VdOOD SHINGLES ❑
improves Ihereon,ena who tloes such work himael�o��hrou8h�Is own employaes,provltleC t�et
suc�improvemanis ere not Inten0e4 or ofleretl lor eale.II,howeveq Ihe Eulltlinp or Improvemen�
issoltlwi�hinonayeerofcompletlon,theowner-builtlerwill�avelhe0urtlenoiprovingNethetlitl OTHER(SPECIFY) �
not builtl ar imOrova for purpose ol sele.).
❑I,as ownor of ihe properry,em evcluelvety contracting with Ilcensetl convacmra�o constmct
ih0 pmjBt�($ec 1044,Businass antl Prolasslans Code:The ConVaclor's Llcenae Lew does not PROVIDE I.C.B.O.REPORT NO.
epP�Y�o an owner o�pmper�y who builds or Impmves�hereon,entl w�o contrec�9 br Such pmlac�s
wim e contrector(s)licensee pursuam m ine Canirector's Licanse Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I em axampl untler Sac. ,B 8 P.Q�or Ihls reeaon
ow�ef DBfe APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I horeby alflrm untler penelty of per�ury ona al t�e followinp declaretion:
- ❑I heva antl will mainlaln e Cetlificate ot Consent to eelbinaure for Worker'e Compansetlon, /� Building
ae pmvitletl for by Saction 3]00 0l�he Labor Cotle,br t�e petlormence ol lhe work lor w�ich lhis ) p Q
p rm� Isissuatl. / � $BISff11C
heve entl will malmaln Worker'e Compensa�ion Inaurenta,es repulred by Sectlon 3]00 0� ��
1 e Lebor Cotla,br the petlormance ol t�a work lor whlc��his permit Ia IssueE.My Workeis / yy . ) �
Compansotion Insurence carde tl Pollcy number ere: T0�8� / Q�
�i�d_�Z3��Oa `
curriar� ���1.�}�mmyNo.- � PERMITAUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSUFANCE N.C.O �
(Thls section neetl not be completetl if Iha permit ia for one huntlretl tlollere($100)or less.)
I certily ihut in ihe petlormance of Ihe xrork lor which this permit Is issueq I sh011 no�employ
a�Y Pe�bo�m a�Y me��a�so as w oe<oma s�nia�no ma wo�ke�a comPe�souo��aws oi car- All roofs shall be inspected prior to any roofing material being
'o`"'a. installed. If a roof is installed without first obtaining an
ome Appllcanl inspection,I agree to remove all new materials for inspection.
eube�c�oElie�WOPke�s�c mPe�seieo provlsloosollhelLabo�Cotlamyoumus�ubtl�witl�bcomply Applicant underst and will comply with all non point
wllh such provision5 or Ihis parml�shBll b0 CeBmBtl ravOkatl. $Ol1fCE f89lll8tl0 S. �
I ce��ily�he�I have reetl ihis epplicelion entl aie�e lhal lhe ebove iniormati0n is LorreCt.I aBree
�ocomplywi��allciryenticoumyordinancasan45tel91ew5relatlngtobulltlingconsVucllon,ene OfCOV@fl❑ �Ob C� SS orbelter.
hereby euthadze represantalivas oi Ihis city�o anter upon�he ebove-men�ionad pmperty tar im � �
epection purpoees.
(We)egree lo save,Intlamnliy antl keep hermless ihe City of CupBrtino egelns�liebilitles, ' � � d 1�d��
�udBmenta,costs enE ex0enses which mey in eny wey accme aBaina�sa10 Clly In consequence
o��heBrentinpolihispermll. SI ATUREO APPCI ANT DATE
1 +' PRE-INSPECTION: PIYWOOD: IN'PROGRESS:
INSP. DATE INSP. DATE ItlSP. DATE
TEAR OFF INSPECTION: BATTENS: • FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
' OFFICE COPY