R 4982 (2) �
PERMIT R_ 4 9 8 2 .
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMITE%PIFATION
REROOF PERMIT �4OB�777�3ZZB PEPMIT E%PIRES IF WOFK IS NOT STARTED
WITHIN 100 OAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM UST CALLED INSPECTION.
BUILDING ADDRES�/' /
•�/) (/ _ �° ///�� (/�
/ \Q �(I���1 � C� ` • RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZA DOUS FIRE AREA
� YES ❑ If yes—I understand ihat e Cless A
NAME � N �LS �� roo�assembly is required.
� � . NO � Initiel I.C.B.O.#
. � ADDRESS �� ^ S� �
� n
PHONE NUMBER OF EXISTING COVERINGS
F CONTRACTO 'S � �
NAME O 1 TO BE REMOVED Tp BE RETAINED�
nooRess � I � • Q � ` .� ��',ti TYPE OF ROOF COVERING
CI7V8ZIP � L� _'t ��
PHONE �-.�� r""Z7�f BUILT•UP ROOF �
NUMBER ASPHALT SHINGLES ,
UCENSED CO CTOFS OECLARATION
I hereby afllrm ihet I em Ilceneetl unEer provlelone ot Chepter B(commenclnp wlt�Sac�lon WOOD SHAKES �
7000)ot Dlvlelon 3 0l Ne Buelneae entl Proleealone CoCe,entl my Ilcenee le In full force entl
eHecl. ❑ ��
ucanae Cieee ^ uc.Numbar P G WOOD SHINGLES �
oete contrector d OTHER(SPECIFY) ❑ �
OWNER•BUILOER�ECIAflATION ppOPOSED
I hareby eHirm ihet I em exampt trom t�e Contrector's Llcenee Lew lor t�e lollowinp reaean.
(Sec.7031.5,Buelneee entl Proleeelone Cotle: Any clty or counry which requlre6 e permit ro
conetmcCelter,Improve,Eemolleh,orrepalrenyetmcture,prbrtolteleauence,eleorequlreethe BUILT-UPROOF �
eppllcent lor auch permlt ta llle e elBneE e�Btemen�ihet he le lican9etl pureuenl to t�e provlelone
ol ihe Conirector'e Llcanee Lew(Chapter e(commencinp with Sactlon 7000)ol 0lvlelon 3 0l Ihe ❑
• Buelneee entl Proleeelone Code)or thet ha le exempt therelmm entl the beala lor the ellepetl A$PHALT$HIN(iLE$ ,
exemptlan.Any vloletlon of Sactlon]031.5 by eny eppl Icant for e permit eublecte the appllcent to
e c�v��pene�ry o�not mom ihen nve hunOreE dol�ere�Ssoo).): �4/OOD SHAKES �_
❑I,es owner ol t�e properry,or my employee6 wl�h xrepee ee ihelr eole compeneellon,wlll Eo
t�e work,entl Ihe etmcture le not IntenEed o�aflaretl lor eele(Sec.7044,Bu6lneee entl Pmlee�
' elone Cotle:Tha Contrector'e Llcenee Lew tloee nat epply to en owner ol Oroperty who bullde or �/�/OOD SHINGLES ❑
Improvee thereon,end who doee euch work hlmaelt or IhrouBh hle own em0loyeee,pmvltletl that
suc�Improvemente ere not Intentletl or oXaretl for eelo.If,howeuer,�he 6ulldlnp or Improvement
Iaeoltlwllhinonayeerofcomplallon.iheownarbulltlerwlllhevethaburEenolprovinBlhethetllC OTHER(SPECIFY) �
not bulltl or improve lor purpaee ol eala.�.
❑I,ae owner al ihe property,em excluelvely conirectinp with II<eneetl conirectora ro conetruct
the prolea(sec.7oaa,Buelnese antl Proteaelene Cotla:7�e Conirecmfe Llcenae Lew tloee not PR�VIDE I.C�i.B.O. REPORT NO.
ap01y to an owner ol properry who builde or ImDrovee t�ereon,entl who conirecle lor euch pmlecte
wlthecomrecmrp�ncaneetlpursuenuomaContrectolellcenealew. PROVIDE MFGR.INSTALLATION SPECS.
� ❑I em exempt untler Sec. ,B i P.C.for ihle�eeeon
owner oate qppLICATION DATE VALUATION PERMIT FEE
WORNER'S COMPENSATION OECLAPATION
I hemby eHirm untler penelry of pe7ury one ol lhe lollowinp deeleretion:
❑I hava entl wlll melnteln e Certlllcate ol Coneent to 6elbinsure lor Worker'e Compeneetlan, BUl�dlfl9
ee provltletl br by Sectlon 3]00 0l tha Lebor Cotle,for t�e petlormence ol the work lor whic�thle
permlt le laeuetl.
�e�C wlll melnteln Worke/s Com eneetlon Ineurenca,ae requlretl Dy Sectlon 3700 al i� G. � (" $BI3f111C
the Lebor Cotle,lor Ihe perlormanee ol l work for w�lc�t�la permll ie IeaueO.My Worker'e � tD��� Total
Campeneatlon In irence c qenE Pollc number ere: 7 ��i rn
� ca��ie� � Pollcy No.^" � ��"' U RIZATION D TE
CEFirIFICATE E%EMPTION FROM WORKEFS'
' COMPENSATION INSURANCE N.C.� t '
(TM1Ie eectlon neatl not be campletetl It Ihe permit le lor one hunGred dollera($100)or leae.) ��/r � � � V�'CI ���'�
( I certlty thet in lhe petlormence oi the work for whlch thla perml�le IesueQ I s�ell not em loy
any Oereon in eny menner eo ee to becrome nubject Io ihe Workero'Compeneetlon Lewa ol�an- All roofs shall be inspected prior to any roofing material being
�o`"1e. installed. If a roof is installed without firs[ obtaining an
oa�a ApPllcan� inspection,I agree to remove all new materials for inspection.
NOiICE TO APPUCANT: II,afl0r maklnp Ihls CBrtI�ICn�B ol ExeRip�10�,y011 s�0ultl blcOme q licant understands and will com I wiih all flOfl Olfl�
eubieci Io Ina Workera'Compenaetlon provlelona ot the Lebor COEe,you muel lanhwtlh comply PP P Y P
with such provislone or Ihls permit e�ell be tleemeE revoke0. SOUfCO IBJU�B}IOf1S. .
I certlfyt�at I heva reeE thle upplicetlan enE etete t�et ihe ebova Inlormetlon IB COf�BCt I apree
to comply wlih all city and counry ortlinencee entl etete lewe reletinp to bulltlln0 conermcuon,antl f��� coveri� s to b C�2SS�Ci"or better
hereby euthorize re0reeentetivee ol thle ciry to enter upon the ebove•men�lone0 propB��y 1p�In- �.
specllon Ourpoaee. s !�/��
(We)egree�o eeve,intlemN�y enC kaep hermlaea Iha Clry ol Cupertlno e EIIIOI Ileellltlee, ' 7
jutlgmente,coeta antl azpaneea whlch mey In eny wey accme egelnet eeld CltyQn conaequonce
• otthapcantlngotlNapermlt. SI UREOFAPPLICANT D TE
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 � �