R-6418 PERMIT
NUMBER R- 6418 .
APPLICATION FOR clrY oP cuPERTlrio
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (418)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM UST CALLED INSPECTION,
BUILDING ADDRESS IS,
0/ / n
�^1
p .mac I I� l` I^^- t` C(,,, Q s 4,-2) RESIDENTIALCOMMERCIAL OTHER—
OWNER'S
THEROWNS 'S HAZARDOUS FIRE AREA
YES ❑ ff yes— understand that a Class A I
NAME —T r,Q iz�h �'� ll Y'A 5 roof Esse ty fs regtdre11.
,,// n n NO ❑ Inlbal I.C.B.O.N
ADDRESS /D T �'� /'*'1r Gi /�' ` "� • C�, 1-1y EXISTING ROOF COVERING
PHONEL O 6� NUMBER OF EXISTING COVERINGS -
CONTRACT�OR'S
/ l (7 � �� � - TO BE REMOVED _ TO BE RETAINED
NAME /( AC./�,7 P TYPE OF ROOF COVERING
ADDRESS
cmazlP f��i�1 Ui kd1Z—, 'QZ4 EXISTING
PHONE SID R 9L Dm BUILT-UP ROOFLICENSE
❑
NUMBER S ASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em Ibensed under prcvtslmS of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business arM Professions Code.and my license Is In lull force and '
ems' ) %'� WOOD SHINGLES
License Claes Lk.Number _5-7 !tg ❑
Data 3�9' f/r ac« ��� Gi.S A e/P� OTHER(SPECIFY) ^ ❑
OWNER-eufi_ E DEQLARA�TIOI PROPOSED
I hereby affirm Chet I sm exempt from the Contractors License Law the following reesm.
(Sec.construct,
It r,ImmoBusiness and Pres,or re Cada: Any dry or county which requiresalso e permit to
apoUnLalter,Improve,dfile a siorrepairarty Structure,he pd«toelesuaxre,Elea requires the BUILT-UP ROOF
applicant for each p-1mlf to La (elhnatl r 9(comm inci he Islicensedp«Buaofto the provisions
me \/
of the ss and Professions
Law(Chaplet 0(commencing with Smtim me h of Olvialhe ale the X
.�
exemption.
xe ptio end Probssione Code)or 0311 he Is exempt therefrom eM the beele fon me alleged ASPHALT SHINGLES
a clvll en.Artyf not
of Swim 7031.5 byartyapplicant for a Permit subjects 038 applicant to
e dvll penalty of not mora then Ove hundred tlollerS($SOOL):
❑1,as owner of the property,or my employees with wages as their Sole compensation,will WOOD SHAKES
the work,and the structure le not Intended or offered for sale(Sec.7044,Business and Proles-
alone Coca:The Cmiractore License Lew does not appy to an owner of property who Wide or WOOD SHINGLES El
thereon,and who does such work himself or through his own emdedployees,provithat
such Improvements are not Intended or offered for sale.If,fxwvever,the building or Improvement
Is Sold within one year of cmpletlon,the owmw-bulbw will have the burden of proving that he eta OTHER (SPECIFY) ❑
not build or Improve for purpose of sale.).
❑1,as owner of the property,em excbsvely contraclinngg with IlCensad conimci«s to coneMlct
Me prciect Sec.7044,Business and Professions Code:The Colin cters License taw epee not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property wino bunds or Improves Mere m,end who conUecte f«such projects -
wiMecontrectors)licensee pureuent to the Contractors License Lew. PROVIDE MFGR.IN$TALLATION SPECS.
I-]I am exempt under Sec. ',B 6 P.C.for this reason
Omer Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following dederatbn: _
1 have and.111 maintain a Certificate of Consent to self-Insure for Workers Compensation, Building / L j
as provided for by Section 37W of ire Labor Ccde,for the performance of the work for which this err
permit le Issued. Y io
❑1 have and will melmaln Workers Compensation Insurance,as required by Sectim 370001 SBIBmIC
the Labor Code,for the performance of the work for which INS permit Is tesued My Wor re / �
Companaatbn Insurance carrier and Policy number are: ppU��M/Tqp00 �6qa Total .Ro
Carrier F "F�:u W > Policy No, 6�-O�'�/ PERMIT AUTHORIZATION - DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ ^ r
(This Section need not be conpleme if the wrmll is for me hundred dollars($100)or less.) •� /j/( 7
I ceelty,that In the performance of the work for whlrh MIs permit 4 Issued,I Shall net em toy
any person In any mauler as as to became Subject to the YIprSk •snppnsatloyLew�1 II roofs shall be inspec ed Prior to any roofing material being
fornix. C rttxo�� a is installed without first obtaining an
Dae 3 /'�/�1 Applicant 6 A-F F !n C actio ,I agr remove all new materials for inspection.
NOTICE TO APPLICANT: II,after making thle Certlffoata f Exaniption,yon abma 'ma A licent tinct nds and will comply.with all non
subject to the Workers'Compensation provisions of the Labor Code,you must IorMwXh c py ^ n pp p y point
with such prevlelons«this.permff shall be deemed revoked. I FI�6�IrCB{e ti
I cefllfythat l have read MIS application and State that the above Information lemrrect agree J f
to comply with all city and county ordinances and state lawn Slating to bulblrg cOnstn cd n,and All roof rl o be class Or better.
hereby eutierize representatives,of this city to enter upon the above-mentkmed prope for In-
-
-�� � l
spectim wmcaee. 7„ S
(We)agree to save,Indemnffy and keep harmless Me cry of Cupertino against I1I1tlea,
Judgments,coats entl expenses which may In any way accrue against Said Cly In cros;muence
0"'
f Ma gran In,of this permit. PP NT DATE
RE-INSPECTION: PLYWOOD: - IN
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