R-6396 APPLICATION FOR CITY OF CUPERTINO
[�NIJMBERRPERMIT
- 6396
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1W DAYS OF PERMIT ISSUANCE OR
1B0 DAYS FROM IAST CALLED INSPECPON.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S / HAZARDOUS FIRE AREA
NAME /f ` YES ❑ If yes—I understand that a Class A
roof assembly Is required.
/p No q{/ InNal I.C.B.O.R
ADDRESS ( /� " uOrj'e dr• EXISTING ROOF COVERING
PHONE Q^ p / NUMBER OF EXISTING COVERINGS (
CONTRACTOR' {�/J()/� �/
NAME h /S, �' rQ �,yp ,C TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP •L1
Exlsnric .
PHONE 33G— —3fn 7� BUILT-UP ROOF ❑
LICENSE L/( ASPHALT SHINGLES ❑
NUMBER
LICENSED CONTRACTORS DECLARATION '
I hereby affirm Net I em licensed under provisions of Chapter a(commencing with Section WOOD SHAKES '
7000)of Division 3 of the Business and Professions Code,end my license is N full tome end .
effect. / WOOD SHINGLES
License Class p^� LIc.Number « P ❑
Dote �d0 Contractor 1 oiL,;� OTHER(SPECIFY) ❑
I hereby affirm that I am exemptfrom Me Contractors License law for the Idlowing'reason,
PROPOSED
(Sec.7031.5,Business and Professions Code: Any dry or coumy which requires a permit to
construct,alter,Improve,donneto Me signed air statement
ntmcturo,p licensedor to Its ssuance,wmuant also to
etls BUILT-UP ROOF. ❑
of ffie ni for etch pxmb a ab a signed sialement that fj 15licensedSvc o Wnuanf to the provolone
of the ss amdPre License Law(Chapter B(commenting with Section Me b of for the 3 0l the
.
exemption.
entl violation of Coda)or Net he Is exempt ant for a entl the beefs for the alleged ASPHALT SHINGLES
axempdon.Anyviolatorof Section hundred
any eppllcantfora permits
e chill.amity of not more peen ave y emp dollars(SSao).):. D SHAKES❑I,k, owner of the property,or my employees:h wages as their so persat r l ❑
the work,end the structure le not intended or offered for sale(Sec.704A nese
eons Code:The Contractors License Lew does,not appy to an owner.. rry who bulkls or % D SHINGLES
Improves thereon,and who does,such work himself or through his own a es,,provoetl tet ❑
"su<3l improvements are not Intended or offered for sale.If,however,the p oQr�ro�ierd�n� 1999
ilii
Is,sold within one year of connotation,the owner-bulkier will have the lou fprovin he l JJ ER(SPECIFY) ❑
not build or Improve for purpose of sale.).
01,as owner of the property,em amiusloely contracting with llcensetl arthe o.to construct
the project(Sec.7044,Business and Professions Code:The Contractor LKpnea Law does not PR VIDE I.C.B.O. REPORT NO.
appy to an owner of property who builds or Improves thereon,and wl,ocotr((ddTglor each ro acts
Mm a contractors)Ilcansetl pursuant to the Contractors License Lew. PR VIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B a P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under peneity of perjury one of the following decleretlon: // 7
'[]I have and will maintain a Cermcan of Consent to sedansure for Workers Compensation, vo Building/Z
as prodded for by Sacibn 37W of the Labor Code,for the performance of the work for which this ( ,{�
permit is Issued. Seismic V O
nd 00
❑1 have ewill maintain Workers Compensation'Insurance,es,required by Section 37of -
the Inbar Code,for the porormance of the work for which this permit Is Issued.My Workers 2
Compensation Insurance carter and Policy number ere: TOt
72 0
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE N.CQ T
(This section need not be competed it Ne permit is for one hundred dollen($100)or lees.)
I cantly Nal In The performance of the work for which Ihia"man Is Issued,I shell not employ
any person N any manner so as,to become subject to the Workers'Ce ,persabon Laws,of call- All roofs shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Data 2/-99 Applicant inspection,I agree to remove all new materials for inspection.
Subject to M WOP a ICCuom nation making
this of Late ol�a pion u should becare Applicant understands and will comply with all non point
I pa p you must forthwith campy
with such prodsiars or this permit ease be deemed revoked. source regulations.
I certify that l have reed this applbatlon and stele that the above Information is correct.I agree
to comply with at dry aro county ordinances and stale laws relallrg to budding mnswcibn,and All roof coveringsz
or better.
hereby authorize representatives of this city to enter upon the above mentioned property for In. -.speWenpurposes. ,j
(We)agree IO save,Indemnity,and may I harmless w as,Ne kt,a of Ct sa a vi agethst equebs, u,�4
I mann
,toes and expenses welch may In anyway accrue against said Clry In wrwaquenca SIGNATURE OF APPL NT DATE
oft a gnntlrp of thn permit. ..
PRE-INSPECTION: PLYWOOD: - IN-PROGRESS:
INSP. - DATE INSP. DATE INSP DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE If DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY