R 6264 . PERMIT R_ 6 2 6 4 .
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
"747-K RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
J VES ❑ If yes—I understand that a Class A
NAME �ESP T LP \ �r7—�C-�L root assembly is required.
- NO ❑ ImWil _ LC.B.O.k
ADDRESS -]4-SS- EXISTING ROOF COVERING \
PHONE L�1O —]3 — y\O NUMBER OF EXISTING COVERINGS r"!i
CONTRACTOR'S
NAME N r L�T�tJ �1t0 Fu fJ G - - TO BE REMOVED TO BE RETAINED '
ADDRESS . - - TYPE OF ROOF COVERING
CITY a ZIP 19��b Lef rid: re.Q%\ LIA EXISTING
PHONE C-65b CIL Ink- 7b-C44 - BUILT-UP ROOFLICENSE ❑
NUMBER �.\VCLI
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
]000)of Division 3 of the Business and Professions Code,and my license Is in full force and
effect WOOD SHINGLES ❑
License Class C=3p\ Lic.Number 2.6 1 Cfc�')
oele—I t- f qCg. ConctorSS` OTHER(SPECIFY) ❑
OWNER-BUILDER
BUILDER DECLARATION PROPOSED
I hereby affirm that am exempt from the e: Any city License Lew for the following reason. / r
(Sec.]ct,alt Business and Profedemolish,
or rep Code: Any city or county which requires a permit to
construct,alter,improve,to file signed statement
structure,e,is 11conse issuance,also requires the BUILT-UP ROOF ❑ /
of t h antCo for each permit a file a signed statement that he ish Sectio pursuant to the pro 01 the
of the ss and r.
License Lew(Chapter h(commencing with Section Me b si Division the ale the
• Business and Professions Code)or 0311 he is exempt therefrom and Me basis for the alleged to ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of no .a .
C]1,as owner of roparry, AA�� employe�s vIlhw slhelr sole compensation,will do WOOD SHAKES
the work,end the I re is n ihkn ed or R.,a for al ea]044,Business and Profee-
slopnsCode:Th0C r tar's nae doe99arrrWWWbtapps owner of property who builds or WOOD SHINGLES
❑
improves
thereon, o does such work himself or thr Is own employees,provided that
such improvement of�q1q0y�tl o re for Bala.I h or,the building or Improvement
Is sold within oney coylepLh,t� nat}61fM41 w1 h the burden of proving that he did OTHER(SPECIFY) ❑
not build or improv rpurOQ�daUV0MM111 ease.). f�JJJJ��
❑I,as owno property,am exclusively contract( t licensed contractors to construct
the project C.] 44,Business and Professions Code: ontramor's License Law does not PROVIDE I.C.B.O.REPORT NO.
applyloenowner pqp�rry who bulltls orimprovea thereon, it who contracts for such projects
with a contractor IIhAMad aam tt the Contractors Lice se Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt u ,S S P.C.for this reason
Owner Date I APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of the following declaration:
uildin
as provided for by Section 3]00 of the Labor Code,for the performance of the work for which this
L]I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, B' -� � fd,
permit is Issued.
Qf4ave and will maintain Worker's Compensation Insurance,as required by Section 3700 of 1 1 1, Seismic 70
the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's z p 'f O
Compensation Insurance carrier and Polity number are: Total V
Carrier L-EG\n\ l policy PERMIT PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CCI �—
(This section need not be completed if the permit is for one hundred dollars($100)or less.)
I cartify that in the performance of the work Mr which this permit is Issued,I shall not employ ( a.J
any person In any manner so as to become subject to the Workers'Compensation Laws of Call. All roofs shall be inspected prior to any roofing material being
terms. installed. If a roof is installed without first obtaining an
Data 1 1- S R!FS Applicant ,0IS-LIC11"a- inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed ranked. 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 laws relating to building construction,and f coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for Im
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, 1.S
o the gr s,code and expanses which may In any way accrue against sale Clry In consequence SIG APPLICANT DATE-
PRE-INSPECTION:
the gmnting of ihl5 patmil.
• PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE 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