R-6204 PERMIT
APPLICATION FOR CITY of CUPERTINO NUMBER R� 6 2a�4 -
INSPECTION DIVISION - PERMIT EXPIRATION
REROOF PERMIT (408)7]7-3228- - PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR -
180 DAYS FROM LAST CALLED INSPECTION. ,
BUILDING ADDRESS
RESIDENTIAL _ ✓ COMMERCIAL OTHER -
OWNER'S HAZARDOUS FIRE AREA
_ YES L] If yes 'I understand that a Clew A '
NAME /��Lg lW&,$ m1f y¢.OR r0of�assembly is required. '
NO- L] - Initial. I.C.B.O.%
X
ADDRESS n 3 : �-N
&rgA, : 'C�1. ,9Sd/5� - - EXISTING ROOF COVERING''.
v - ' NUMBER OF EXISTING COVERINGS J...
PHONE -
CONTRACTOR'S -
NAME �GfIA6W45;ci' .TO BE REMOJED-
TO BE RETAINED
ADDRESS
TYPE OF ROOF COVERING
� -
. clTJazip— P O. pe.oX 35'.583' MoiV�F x�nr..�
r 9so3a. EXISTING .
7- 3'✓
PHONE _ BUILT-UP ROOF •, •�, ❑"
LICENSE
NUMBERa7Z9Z.$ ASPHALT SHINGLES ❑
- DCENSED CONTRACTORS DECLARATION +-
'I hereby affilm that I em licensed under provlelom of Chapter a(commending with Section v. WOOD SHAKES
7000)of ovation 3 of th Business and Professions Code,and my Ikenee Is,In lull force and
enxL WOOD SHINGLES
Ucenae Claes`_ Llc.Nu .q
'
Date— 9 Can - 'OTHER(SPECIFY) ❑ - ..
. - NER- ERDECIARATION - .PROPOSED. -
hereby atflrm that I em exempt The Contractor's Ucense Law for the folfowl lesson. -
n9
(Sec.]031.5,BuelnesserM P one Code: Any city or county which requires a permit to
_--cpnetmc6 ener,lmprove;demo or repair any structure,prlor to its Issuance,also requires the BUILT-UP ROOF-- -❑applicant for such penult to Ills a signed elatemem Met he Is Ilcensed pumuent to the provla10
of Me Contractor's License Law(Chapter 6(commenclng wlm Section 700, of DNlslon 3 of t
Business entl vic4atdone Cotler or that he le exempt therefrom end Me)sols for me snag ASPHALT SHINGLES ❑
exempikm.Arty viclatbn of Section 7031.5 fry any applicant for a permit eubpcte drt epplfoa
a clNl penalty of not more Man five hundred dollars($600).):
• ]I,asownerofthe property,or my employees with wages as their see compensetlon,will do WOOD SHAKES ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Buelhese and Profee-
Mons Code:The Contractors Ucense Law dose nooply to an owner of property who bulloa or D INGLES ❑
Improves thereon,and who does such work hl I r lou hie own empbyees,provldad that
such Impmvemenb ere not Intentletl or Dive for a waver,the bulloVng or Improvement
H add witmn one year of completion,iheo -foul r' Il neve to buden of prming that he did OTHE (SPECIFY) � OW
not bulla w Improve for purpose of Male.). -
❑I,ee owner of the property,am exclusively contracting with licensed contractors to cavtrud asB�,rao k/r
a project(Sea.70 ,Business and Professions Cade:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
Mapply to an 46owner of property who builds or Improves Merton,and who contracts for such projects '
with a contractor(s)licensed pursuant to the Cantredora Ucaee Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. - ,B&P.C.for inle.reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby efflrm under penalty of perjuryone of the following declaration:
❑I have and will maintain a CedHkete of Consent to self-Insure for Workers Compensation, Building
as proAtled]ur by Section 3700 of the Labor Code,for the performance of Me work for which this
bennitI use. '' � 3 Z Seismic Fo
Veve and will maintain Workers Compensation Insurance,art required by Sectlon 3700 of
the Labor Code,for the perfarmence of the work for which mle permit Is Issued..My Worker's
Compersatlon Insurance cd'er and Polley number ere: /3/o Total
rarN
Carrier STARI NP - PalcyNo.W� S;r.9y PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FBCIM WORKERS'
y(; COMPENSATION INSURANCE N.C{] e
- (this section need not be completed If the permit Is for one hundred dollars($100)or leas.)
8.-733Z I cenlfy that In the performance of the work for which his penult Is Issued,I shall not employ
/ any person In any manner eo ae become subject to the Workars'Compenainon Laws of Call. All roofs shall be inspected prior to any roofing mated I being
forma. installed. If a roofisinstalled without first obtaining an
Date m inspection,I agree to remove all new materials for inspection.
NOTICE TO APPUCANT: H, r making this Caditloefe of Exemption,you should becomt Applicant understands and will co I with all non Dint
subject to the Workers'Compensation provlecns of the Labor Coda,you must forthwith comply PP ply P
with such pro films or this permit shall be deemed revoked. Source regul -
I certify that I have read this application and state Net the above Information Is correct.I agree (� '
to comply with all city and county ordinances and date laws relating to bullmng construction,and All coverings I is or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection xuposes. / 4
(We)agree to save,Indemnity arm keep harmless the City of Cupertino agalnet Ilabllltles,
judgments,costa end expenses which may In any way accrue against said City In consequence
• of me grantingof this permit. ATURE OF XPPLICDATE
PRE-INSPECTION: PLYWOOD: . IN-P ESS:
• INSP. DATE INSP. DATE IN DATE
TEAR OFF INSPECTION: - BATTENS: F AL: -
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY