R 6266 (2) r
PERMIT q_ 6 2 6 6
APPLICATION FOR CITY QF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (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
C&rro twljooh e ` . RESIDENTIAL COMMERCIAL - OTHER—
OWNER'S
THER
OWNER''S`' 1� +L HAZARDOUS FIRE AREA
NAMELINUA PNI� IP.J YES ❑ If yes—I understand that a Claw
roof assembly is required.
NO Initial I.C.B.O.q
ADDRESS 6? Ci t,) WOO fl CF. EXISTING ROOF COVERING
PHONE J NUMBER OF EXISTING COVERINGS ,
CONTRACTORS
�� /^I
NAME ILY�NAIS¢3ANP� COof1NG Cil NL• TO BE REMOVED TO BE RETAINED
ADDRESS zz Z S� q�j TYPE OF ROOF COVERING
CITY&ZIP Lam-{ AV 6 ` _ EXISTING
PHONE f1�-' _ BUILT-UP ROOF ❑
LICENSEL-7��
NUMBER 7J 1 ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION '
I hereby affirm that I am licensed underprovisions of Chapter 8(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my Ilcenae Is In IUII force and
ansa. 1 WOOD SHINGLES ❑
License Class � `'? Lia Number �� `��� p � a
Date Contractor&^ AA6SANC.6 LOOFIn1l�CO- OTHER (SPECIFY) ❑ Q
OWNER-BUILDER DECLARATION PROPOSED /
I hereby affirm that I am exempt from the Contractor's Ucense Law for the(allowing reason. -
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF E]applicant for such permit to file a signed Statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter g(commencing with Seaton 7000)of Division 3 of the
Business and Professions Code)or at he IS exempt therefrom and the basis for the alleged ASPHALT SHINGLES
• exemptlon.Any violation 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),); WOOD SHAKES p I,w Owner of the property,or my employees with wages as their sofa compensation,will do ❑
the work,and the structure is not Intended or offered for sale Sec usineea and Profes.
slons Code:The Contractor's Licens owner of IF operty who builds or WOOD SHINGLES
Improves thereon,and who doe work hlr�pa�(or throu Is ow a throw,Provided that � ❑
such Improvements are not Into Qegor site retl/oi.sl09.If,h er,in Ing or improvement
IssoldwithInane yearofompIs 0 IAsawddda6buiMeT will he ethobu e I proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose son).
❑I,ae owneroltheproperry, xcIusIvel ntgcVX, se c rectors to construct
the project(Sec.7044,Business Pr0b9 CbyaiJh� cto ansa Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an Owner of property wh b Ildso r st arson,and who n to for such projects
with a contraaor(e)licensed pur nt to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
I]I am exempt under Sec. ,B& C.for this reason
ownerWORK IRPSCOIPPER TION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under peneiry of perjury one of the following declaration: I
❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, � �')1 BUIId In
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this II"Gf O.Iv� �'� g
permit Is Issued. dWWW1�"' Seismic
■ neve and will maintain Workers f the work
Insurance,as required by section 370001
the Labor Code,for the performance Of the work for which this permit Is Issued.My Worker's � {`�
Compensation InsurAance carrier end Policy number are: Total
Carrier g�t � ���� Policy No. �lNbAu 3 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the permit Is for one hundred dollars($100)Or lees.) \J
I certify that In the performance of the work for which this permit is issued,I shall not am toy
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
torrid' installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subjects too th WorkeAPPLICANT:
s Com enafter
too provisions at theflcate of Laborr Code,you must forthwithecome
Applicant understands and will comply with all non point
with such provisions or this permit shall be doomed revoked. y comply Source egulations. -
I certify that l have read this application and elate that the above information Is correct.)agree
to comply with all clryand counryoNinences and state laws relating to building construction,and - AllringS eclass"O°Of better.
hereby authorize representatives of this city to enter upon the above-mentloned property for In.
spealon purposes.
(We)agree 10 save,Indemnify and keep harmless the City of Cupertino apshot liabilities,
apse granting of this permit,ea which may In dry way Accrue against eelq City n coneoquence SIGNATURE OF APPLICANT DATE
• 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY