R 5926 APPLICATION FOR
. CITY OF CUPERTINO
Nu e'RR- 5926
. � INSPECTIONDIVISION PERMITEXPIRATION �
REROOF PERMIT — � � �4OB�777-.�EZB PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
• 1B0 OAVS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
� �� � � RESIDENTIAL �COMMERCIAL OTHER
NER's HAZARDOUS FIR�,AREA
/,•p �(�� VES ❑ If yes—I underetand that e Class A
NAME����Ffrs n� („fe(� L' 7� roof essembly is requlred.
NO ❑ Initial I.C.B.O.N
ADDRESS 3 EXISTING ROOF COVERING
� PHONE � � NUMBER OF EXISTING COVERINGS �
- CONTR TOR'S ,
� TO BE REMOVED � TO BE RETAINED
NAM
� ADDRESS TYPE OF ROOF COVERING
cirv s zi� .��
EXISTING
PHONE /—r�(���'�u-�--s-.3 BUILT•UP ROOF ❑
LICENSE � /,
NUMBER �' y�- ASPHALT SHINGLES ❑
LIC NSED CON MCTORS�ECLAMTION
I here0y eHirm thet I em Ilcanaetl untlar provlelone ol Cheptar B(commencinp wlth Sectlon WOOD SHAKES �
7000)of Divlelon 3 0l tha Buelneee entl Profeeelone Cotla,entl my Ilcenae la In full brca antl
I ' eneC� � �iJ..^ 3�� D SHINGLES ❑
Llcenae Cleee Lic.Number
oete contrector
O (SPECIFY) ❑
OWNER�BUILOER DECLARATION pROPOSED
I heraby eHlrm Ihet I em ecempt from ihe Contrector's Licenee Lew lor ihe kllowlnp reaeon.
(Sec.7031.5,Buelneaa entl Pmleaelone Code: Any city or county which requlree a permit to
constmcM,elter.Improve,tlemolleh,orrepelrenyetmcture,prlorrolteiesuence,eleoreQulreatne BUILTUPR�OF ❑
applieent for auch Oermit to flle a sIB�eE atetement thet he le Ilceneetl pureuent to the provislona
oi the ConVectofs Llcenee Lew(Chepter B(commanclnB'M1'��h Sactlon 1000)o�Dlvlelon 3 0l lhe
• Bu6lneea entl Profeeelone Code)or thel he le exempt theretrom antl the beela lor tne elle0etl A$PHALT$HINGLE$ ❑
axemptlon.Any violetlon of Sectlan 7031.5 by eny epplicent br e permlt aub�ecte the eppllcent to
e civll penalty of not more Ihen fiva hunEratl tlollere(5500).): �
❑I,eaownerofthepraperty,ormyemployeeswlthwegesaathelreolecompensetlon,wlll0o WOODSHAKES
the work,anG tha etrucNre la not Intentletl or oXeretl lor eele(Sec.7044,Buelneaa entl Profea�
elone CoEe:The Contreaora Llcensa Lew tloes not eOPly to en owner ol property w�o bullEa or y�/pOD SHINGLES �
Impmvee thereon,antl who Eoee suc�work hlmael/or throup�Ne own employeea,pmvltletl��et
6uch Improvemente ara not Intentlatl or oHemtl for nele.If,howeveq the bulltllnp or Impmvamenl
� Ie6oIEwl�hlnonByBBrofcompletlon,��eowner�bulltlerwlll�evathBburtlOnofpmvinpUa�hatllE OTHER(SPECIFY) , ❑
nat bu11E or Improva lor purpoea of ealeJ.
' ❑I,eeownerofNaproperry,emavcluelvelyconVedinpwit�licenseticontrectoretoconalrucl
Ihe pro�eR(Sec.7044,Buelnece entl Proleeaione COEe:Tha Conlractofe Licenae Lew tloee not PROVIDE I.('..B.�.REPORT NO.
. eppryroenownerolpmpertywhoEUllEsorlmproveethemon,antlwhoconlrectelOrauthpro�acta
wliheeontmcmr(e)IlceneeEpureuenim�heCono-anorbLlcenee�ew. PROVIDEMFGR.INSTALLATIONSPECS. U /� P,��
- ❑I am ecempt unCer Sec. ,B 6 P.C.Wr thla reeson �I
owner oe�e APPLICATION DATE VALUATI N.. PERMIT FEE
WORKER'S COMPENSATION DECIARATION
I hereby eHlrm under penelry ol0erjury ane ol ihe lollowinp declaretlon; '� ��
❑I heve en7 wlll melntaln e Cartllicele of Coneent lo eelf-Innure lor Workale Compenaetlon, lll�dl❑
as pmvlCed for by Sactlon 3700 of�he Lebor Cotle,lar the pedormence of�he xro�k br which Ihla 9
perml�le leaued. � �� Q$ b�9 AN ' _ ,�
❑I have end wiil meinteln Worker's Compeneetlan Ineurence,ee requlretl by Sectlon 3700 of ! BISff11C
Ihe Labo�C e,lor tha petlo�men f�he wo�k lo�whlc��hle pe�mll le Iaeuad.My Workefe p Oe
Compensa' Inaurenpecertlere II numb ye: ' �ufcni irTO�el O•
cerr� � / koncy � PERMITAUTHORIZATION DATE I
CERTIFICATE OF EXEMPTION FR�M WORKERS'
- COMPENSATION INSURANCE N.C.[] ��
(Thle eectlon neatl not be completetl II Iho permit Ie lar one huntlretl tlollare(5�00)or leee.) J �� ^ ^ O _
I ceriity�he�In Ihe pertormente of tha xrork br which Ihle permli Is leeuatl.I ahall no�employ ��� - �
a�r ve�.o�i�a�r me��a����o ea�ama a�niaci�o me wo���a�comPa�sano��wa ai cen. All roots shall be inspected prior to any roofing material be�ng
�0f"�' installed. Ii a roof is installed wilhout first obtaining an
oe�a AppllCeni inspection,I agree to remove all new materials for inspection.
Bube�toEheWorkaue'C mpeneatlonprovleionleot�ha'ILebo�Cotlamyolumuntulon�wltlhbcompry Applicant understands and will comply with a�l non point
with auc�provlelone or thie parmit e�ell Ee EeemaO rovoketl. SOUfCB fB9U�8tIOfIS. •
I certlty t�at I hava reatl Nle epplleetlon en0 atala thet the ebova Inlormetlon Is wrreet 1 aBree
tocomplywllhellclyenOcountyortlinenceeentleterolewereletlnptobulltllnpconatmclloqantl Allroofco/v�f/p1gstobeclass�Ci"orbetter.
hereby euthotlze represenletivee ol Ihla tity to ente�upon tha abwe�mentlonetl pmperty kr Im �//.'!/��� �� O �O
e0ectlon purpoaes.
(Wa)epree to eave,indemnity entl keep�ermleee IM1e Clry ol Cupertlno epalnet Ileblllllee, 7. 2
�uCpmen4,coeta entl expeneef wMch may In eny wey eccme epelnsl eeld CIIy In con6equence
• ounas�ancnqotmiepermu. SIG UREOFAPPCICANl' DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
� INSP. DATE INSP. DATE INSP. DATE I
TEAR OFF INSPECTION: BAITENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE�PROVIDED FOR INSPECTION
OFFICE COPV I