R 6172 PERMIT R_ 6172
APPLICATION FOR CITY OF CUPERTINO NUMBER
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.
BUILDING ADDRESS rG Q /
I (J ST£E PL_IF C HAS F ,ft-0 RESIDENTIAL G� COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
�)`I-t n f� ^D�/ ! y7 �'�� #7 YES �" If yes-I untlehe and that a Clas A
NAME F—�' 1 l'JO i-� ��. 1 roof assembly is required.
NO ❑ Initial I.C.B.O.#
ADDRESS C' EXISTING ROOF COVERING
PHONE —`J `.2� ''Z 0 S'� NUMBER OF EXISTING COVERINGS
CONTRACiTiOR'S -
NAME_ J•� )f-OOT fill TOBEREMOVED J'Hf-f-& TO BE RETAINED
ADDRESS /' ( '1, TYPE OF ROOF COVERING
CIN B ZIP �'I�1Pie ^
' �oSL` Gq I J 5 t L.-1 EXISTING.
PHONE Lc o 8 ^ `Z��-- L��� _ BUILT-UP ROOF ❑
LICENSE r:,C 2
NUMBER ,� ,� 5733 w ,� - ASPHALT SHINGLES ❑ '
UCENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 0(commencing with Section WOOD SHAKES
7000)of Dlvlslon 3 of the Business and Professions Code,and my license is in full force and Y'
meet. WOOD SHINGLES ❑
License Claes P C"� Q Lic.Number�I��J -+`-'
Date 1 T I /� Contractor sl t eD0'�1/.( Co OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby eillrm that am exempt from the e- Any
License Law for the following permit
t.
(Bac.construct,
lh Business and Profedemolish,
or rep Code: Any city or county which requires e permit to
applicant for
su improve,to Zile signed sta any structure,Is licenseor to Its Issuance,alsoreprovisthe BUILT-UP ROOF ❑
applicant foreach permit to lila asignedstatement nci g it licensed pursuant to the provisions
of the Contractor's License Lew(Chapter a(commencing with Section 7000)of for the 3 al the
•
Business and Professions Cotle)or the.he Is exempt therefrom and the su basis for the alleged ASPHALT SHINGLES
exemption.Anyviolationof more
of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more Than five hundred dollars($500).):
❑1,as owner of the property,or my employees with wages as their sole comperI
,wlll tlAKES ❑
the work,and the structure Is not intended or offered for sale(Sec.7044,BusineProf -� 1
slons Code:The Contractor's License Lew does not apply to an owner of proper) beim OD INGLES
improves thereon,and who does such work himself or through his own employeetletl that ❑Such improvements are not intended or offered for sale.II,however,the building cov ��®IS Gold within one year of completion,the ownerbullder will have the burtlan of prat� YE . PECIFY)no. rulld or improve for purpose of sale.).❑I,as owner of the property,em exclusively contracting with licensed contractonstruct
the project(Sec.7044,Businese and Professions Code:The Contractor's Ucens oes not P I.C.B.O.REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts to ayg�projects -
with a contracmgs)licensed pursuant to the Contractors License Law. 66 MFGR.INSTALLATION SPECS.
1]I am exempt under Sec. ,B 8 P.C.
Owner oats
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ 07
I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, � Building
as provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this I O� I��� � 55 Lt IN g / ^
permit Ift...and
Seismic
have and will maintain Workers Compensation Insurance,as required by Section 3700 of
the .bar Code,for the performance of the work for which this permit is issued.My Worker's Total
Compensation Insurance
/carrier
!and
Policy
(number are: `� �{
Carrier 9T�T LT 1- U&J"•A Policy No.17?) +) 8s— )� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.Op /� —1 9
(This section need not be complatetl if the permit is for one hundred dollars($100)or lees.) p
I certify that in the performance of the work for which this permit Is issued,I shall not employ
any person In any manner so as to become ub t to the Works S'Co pensation Ifea�s of Cali. All roofs shall be inspected prior to any roofing material being
fornia, Q installed. If a roof is installed without first obtaining an
Dale ^ I .- " Applicant !I inspection,I agree to remove all new materials for inspection.
subjects 10E.the Workers'Compensation prov ionr makit is ofeiheflcate of Laborr Code.yooio sho hcombecome
icy Applicant understands and will comply with all non point
with such provisions or this permit shall be doomed revoked. source regulations.
I certify that I have read this application and state that the above information Is correct.I agree ,�,,(�
to comply with all city and county ordinances and state law$relating to building construction,and All rO, coverings t0 be 1 ',.JQr better.
hereby authorize representatives of this city to anter upon the above-mentioned property for In-
spection 7 n
(We) purposes. /V-r/-3_ �V
(We)ogres to Bade,Indemnexpenses
and keep harmless the City ai Cupertino y Inagainstcon liabilities.
judgments,the gran costs and expenses which may In any way accrue against sem Clry In consequence
• of the granting of this permit. NATUREOF PPLI DATE
PRE-INSPECTION.' PLYWOOD: IN-PROGRES
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