R-6029 PERIM
APPLICATION FOR CITY OF,CUPERTINO NUMBERR_ 6029
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-.3228 PERAIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
RESIDENTIAL---Y—COMMERCIAL OTHER
OWNER'S _ _ HAZARDOUS FIRE AREA
— /� VES ❑ N yes=I understand that a Class A
NAME 01 V Lel ,� •42- roof assembly is.required. .
NO E] roof
I.C.B.O.R
ADDRESS '5 'e— _ EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS 411-
CONTRACTOR' 1 _ -
NAME 7h� �nI-` ck u��C TO BE REMOVED�TO BE RETAINED "
ADDRESS ` - TYPE OF ROOF COVERING
clrY a ZIP
EXISTING
PHONE J — 1 O� 33 BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES
LICENSED OONTRACT09S DECLARATION
I hereby a81nn that I an licensed under prevalent;a Chapter a(commencing with Sectep WOOD SHAKES ❑
7000)of Divimon 3 of the Bumness arts Profession,Cods,end my license is In lull force and
effect' ,¢ WOOD SHINGLES
Ucerl Clem C 3 q Uc.Number El
Date conhadoMZi OTHER(SPECIFY) 20
OW from BUILDER DECLARATION PROPOSE
hereby .Bu that I am exempt hose the e: Any city or coca Lew for the brewing reason.
(Sec.7031.5,Business entl Protemlone Cada: Airy Gry or county whlon requires a permit to n
construct,slier,Improve,dertamy,
lish,or repair almaure,prior to Its Issuance,also requires the UI -UP 00 I i[JXL�
applicant for such permit to file a signed statement stateent that he Is licensed pursuant to the provlelons
of the Comactor'e Ucense Law(Chapter B(commencing with Seceon 7000)of DNlslon 3 of the
Business and Praeesens Cade)or that he is exempt therefrom enc the basis for the alleged LJASPHALT HINGL_EZu U
exemption.Any veleten of Section 7031.5 by any applicant for a permit subjects the applicant to 6E Ivk R
e dv11 penalty of not more than he hundred delete
01,as owner of the properly,or my employees with wages as their We compensation,will do WOOD SHAKES ❑
the work,and the atrucMe Is not Intended or offered for sale(Sec.7044,Busirl and Proles- -
slons Code: The Cent does Ucase Low does not apply to an owner of property y he builds or jQInOD SHI ❑
Improves thereon,and whotloee each work MmeNf or through his own empkryem,provided t jY
such improvements are not Intended or offered for sere.If,however,the building or Improvement
is edit within one year of completion,the owner-bulider wID hove Me burden of proNng that he did HER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑1,as owner of the property,em exclusNaly connecting with licensed contractors to construct
the project(Sec.7044,Business and Professlons Code:The Contractors Llceom Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who Whits or Improves thereon,and who contracts far such projects
with a con tenor iff Ieensetl pursuant to the Contractors License Law.
❑1 am exempt under Sec. ,B a P.C.er din reason PROVIDE MFGR.INSTALLATION SPECS.
Own er Diode
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following tleclaratlon:
m pprrwld�etl for b.111
uSectlon 3700 Certificate
1 the LaboriCoode for the pe urmerra of Ms rwoA,fo vMcahth Building
permit Is issued. - / �w TSeisotal G 7 0
❑1 have arM will molmaln Workers Compensation Insurance,as required by Section 3700 of `/'�� X �J l((� �r 7
the Labor Code,for the performance of the work for which this permit Is issued.My Workers [ C7
Compenset Insurance carder end Pdlry number are:
V Total
Cenler r 1 Q-LyL V�/ _110M Pdlry No.111O M3413 30 PERMIT AUTHORIZATION DATE
CERTIFICATE OF E(EMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.]
(This section need not be completed If the persalt la for one hundred collate($1 D0)or less.) � .-
I certify that b the performance of Ne work for which bib pernat Is Issued,I shell not employ
arty,pumon In any manner so es to become subject to the workers Comparsailgn Lava of Call- All roofs shall be inspectea prior to any roofing material being
roams. - installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,after making this Ceruficete el Examples,you should become Applicant understands and will comply Wltfl all non point
subject to the Workers'Coalwsaten provisions of Ne Labor Cade,you must forthwith comply pP p Y P
with such proybions or this permit shake¢deemed revoked. Source regulations-
1 ceNly Met I have read this application and state duet the above Information Is correct"I egret
to comply with ell city and county ordinances and state laws relating to bull0ing constmctlon,entl All roof coverings to be class"C"or better.
hereby authorize raprmentetives of Nle city to enter upon the above-menibrretl property for In.
sp purposes.
(We)
(We)eprm to cave,intlemnity an keep harmbm the City of Cupertino against Iledlltim,
Judgments,toes and expenses which may In any way accrue against said City In consequence
of me granting of Ihla permit SIG SIGNATURE RE OF APPLIG�NT 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY -- '�