R 6350 (2) APPLICATION FOR CITY OF CUPERTINO
nPE a RR- 6350
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRES
110173 ► W/Et. q� - DP,.
CL(PER.T/NO r CA 6:L
fJ-0 14- RESIDENTIAL {✓ COMMERCIAL OTHER
OWNER'S `' HAZARDOUS FIRE AREA
NAME J U D Y RE 7 IFS YES ❑ If yes s I understand That. Class A
roof assembly Is required.
NO ❑ Initial LC.B.0.8
ADDRESS Io73( •P7 PD0KW Ei L p R• ) CqP 6 P.T I�b EXISTING ROOF COVERING
PHONE O (2J• 1793 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S - O
TO BE REMOVED 2 TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby inion that em Business
and
Pr fessi ns of Chapter g(commencing wlih Section WOOD SHAKES ❑
7000)of Division 3 of the Busineee antl Profaeelone Code,and my license Is In full lone and
effect:
WOOD SHINGLES ❑
License Claes Lic.Number
Date Contractor
OTHER(SPECIFY) ❑
OWNER-the Conn DECLARATION PROPOSED /
hereby affirm that I am exempt from the Contractor's License Lew for the following reason.
(Sec.construct,
It Business and Profedemolish,
or rep Code: Any city or county which requires a permit to
sopicangalter,Improve,to file signed air statement
eny menthatstructure,prior to Pelee r ant,Ce,ysOzegr C a BUILT-UP ROOF ❑
applicant for such permit to flaw a signed etetemenl that with
licensedction reBI f olIthe pr a e
• of the Contractors License Lew(Chaplet h Is exa pmt with Swcagn 7000)of�Dpisthe f e
Businessx exemption.
antl Professions Code)or that he Is y doplahmelrodl enri the seal J r the qe ASPHALT SHINGLES
aomt aon.Any viols more than ionfive 7031.5 hundred anyepplic0).lec4 permlitt eLbJedethe appli b
a civil pe try of not more then Ilvo hundred dollars($500J.):
,asowner of the property,or my employees whirr wegep as their Eye ppmpQg'%%n, II WOOD SHAKES ❑
the work,and the structure Is not Intended or oHoreV torrsaltjt glt,r70 al aea� d '
sions Code:The Contreclors License Law does nolo pay to an owner of property who bu o WOOD SHINGLES
Improves thereon,and who does such work himself r.hrough his own employees,provide the ❑
such Improvements are not Intended or offered for sale.11,however,the building or Improvemen
is aoto within one year of completion,the owner-bulldir will have the burden of proving that h Id OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
01,as owner of the property,am exclusively conlrictnna wit licensediontr�to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who Wilde or Improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Lew.
am ox PROVIDE MFGR.INSTALLATION SPECS.
l l untle,Sac. ,B B P.C.for this reason
owns Datu PENSATION DECLARATION R ER's APPLICATION DATE VALUATION• PERMIT FEE
O
I hereby affirm under ally of perju one of the following declaration:
1 have and will maintain a Certificate of Consent to aelfdnsure for Workers Compensation. Building
permit Is issued, I,)to. Seismic
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit Is Issued.My Workers 7
Compensation Insurance carrier and Policy number are: Total J�o
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE sector, .C.D
(Tulsector,need not be completetl it the permit Is for one hundred dollars($100)or lase.)
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any person In any manner so as to become subject to the Workers'Componsatlon Laws of Call- All roofs shall be inspected prior to any roofing material being
tame'��� �s �J installed. If a roof is installed without first obtaining an
Date L`J$�� Applicant —!� p inspection,I agree to remove all new materials for inspection.
subject aroET Workers' NT if,after
parovlsloh I Irun1Leb rf Ee,lptlon ou should become Applicant understands and will Coro I with all non oint
you el forthwith comply source regulations. p y p
with such provisions Wo keor Co permit shall ro dee etl revoketl.
I cenily that I have read this application and stale that the above Information le correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof Coverings.to be Class 1�or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino ogalnst liabilities, -�
lutlpmonts,Coale and expenses which may In any way accrue against sold City in consequence
• of the granting of this permit. I N RE PLI ANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROD ESS:
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
a�
OFFICE COPY