R-6638 PERIM R_ 663
8
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION PRM ,wlRArl N
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
/040 (o
_ RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE ARU—
YES ❑ • N yes-I understand that a Class A
_ NAME_ _ _ / / ! - roof assembly is required. .
IF NO ❑ Irdtlal I.C.B.O.N
ADDRESS � � EXISTING ROOF COVERING '
PHONE Z �' 3 NUMBER OF EXISTING COVERINGS
CONTRACTO O
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS /O q,a QµA - JO TYPEOF ROOF COVERING
CITY&ZIP /lam ,
EXISTING
PHONE r�� 6 8 Z �Z-33 - BUILT-UP ROOF 0
LICENSE
NUMBER Z5 3� - ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECORATION
I hereby affirm that I am lkenwtl under provislona of Chapter 8(commencing with Section WOOD SHAKES
7000)of Divelon 3 of the Business are Professions Code,and my license b In full force and
effect.
3 15 3/ WOOD SHINGLE ^
Lkrenw Cls Uc.Number40 `_ �v\
Dale . la 2-00 Cwtredor OTHER(SPECI ❑
OWNER-BUILDER DECIARATIO - " UN
I hueby affirm that I em exempt from the Contractors"rise Law for the folfowlrq reason. eY s
(Sec.7031.5,Business and Professions Code: Any ctly a county which requires a permit M �y
construct,after,Imv,prodemptiah,or repair any stneturs,prior to Its eeuance,also requires the BUIL P 99
appticlua for eudt permit to Nle a signed statement that he Is licensed pursuant to the Provisions
of the Contractors License Lew(Chapter 8(wri menti with Section 7000)of Dlvlelon 3 of the
Sueness and Professions Cade)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLE$
ewmptlon.Any violation of Section 7031.5 by any applicant for a permh subjects the applicant to
e cNll penalty of not more than five hundred dollars($500).): ,
0,as owner of the prop",or my employees with wages as their We compensation,will do WOOD SHAKES
the wont,and the structure is not Intended or offered for eels(See.7044,Business and Prefers.
sione Code:The Contractors License Lar does not apply to an owner of property who builds or WOOD SHINGLES
improves thereon,and who does such work himseff or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.If,howayer,the building or Improvement
Is sofo within one year of completion,me ownerbullder will have the burden of proving that he dm OTHER(SPECIFY) ❑
not bulfo or Improve for purpoes of sale.). _
❑I,as owner of this property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business srel Professions Code:The Convectors Ucsnw Law does net PROVIDE I.C.B.O. REPORT NO.
app to an owrerol propartywho bullde or improves thereon,and who contracts breach proji
with a centractor(s)Ibensed pursuant to the Contactor,Ucww Law. PROVIDE full INSTALLATION SPECS.
[jm I aexempt under Sec. ,B a P.C.for this reason
Omer Data
WORKERS COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
-
I hereby affirm under pwelty of pertury one of the following tlscuretion:
❑I hew arid;will maintain a Certificate of Corel to self-insure for Wonbrs Compensation, Bulldin
- as provfoed for by Section 3700 of the Labor Code,for the performance of the work for which this
, g L�
Pei hi baud' Seismic
,gl haveand will taped Workers of
for which Insurance,asrequiredisla by Section3700 of /�j�199 $� / -v
m6 Labor Code,for the penormence of tM weak for which ale pemdt is beued.My Workers Qa
Compensation In ,canoe caner and Policy number ere: Total 3 7.
Cure2
Carrier.XC.G•'' �`�� Policy No IF'-5 & ��� 6 PERMIT AUTHORIZATION - DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed II the perMt Is for one hundred collars(5100)or
few.)
I certify that In the performance of the work for which this permit is Issued, shell retamp by
say person In any manner so as to became subject toe erkars'Compensation Laws e1 Cao- All roofs shall be inspected prior to any roofing material being
fornle, minstalled. If a roof is installed without first obtaining.an
Date ` 5 Applicant inspection,I agree to remove all new materials for inspection.
NOTICE Td APPLICANT: If,after making this Certificate Ewmphon,you should become A IJCaflt understands and will COfTI with all non int
Subject to the Workers'Compensation previsions of the Lebo Cade,you must forthwith comply pp pry PO
with such provelons or this permh shell be deemed rewked. Source regulations.
I certify that I hew reed the application and State Chet the all Information Is correct.I agree
to compy with all city and county ordinances and state laws relating to building constructor,and All roof Covell be CIBS'.6"or better.
hereby euffil repraionativee of this city to emer upon the above-mentioned property for Int
apatite,p°rpa to . � G ,-s 9
(Vye)agree to sew,Indemnify end leap hermfoss me Clry of Cupertlro epsum leblHes.
Judgments,costa and expenses which may In any way accrue against said Clryin caneepuerrce
of the grandingoIN*permlt. SIGNATURE OFA LICANT ATE
' PRE-INSPECTION:. PLYWOOD: IN.
ROGRESS:
INSP. DATE If DATE INSP. - DATE
TEAR OFF INSPECTION: BATTENS: - FINAL:
If DATE, INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY