R-6502r
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PERMIT R_ 650 2
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION
REROOF PERMIT •. (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 18D DAYS OF PERMIT ISSUANCE OR
18D DAYS FROM LAST CALLED INSPECTION. '
BUILDING ADDRESS
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K-�RIYQ AJ
RESIDENTIAL COMMERCIAL CTHER
OWNER'S
HAZARDOUS FIRE AREA
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VA
YES ❑ If yes —1 understand Nat a Class A -
U / V/
NAME _ _ A y r 1
roof asmnEly is required.
NO ❑ Initial I.C.B.O.!
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EXISTING ROOF COVERING
ADDRESS
Y'�'
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ir`
lay
PHONE O
NUMBER OF EXISTING COVERINGS y
1
TO BERCVED TO BE RETAINED
EM
CONTR/A/C�� 'S /'
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NAMER
ADDRESS S
Cm a ZPl
F ROOF COVERING
IEXIIING 1999
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PHONE
BUILT-UP ROOFLICENSE
NUMBER
ASRkfAL
LiCFSISE CTORS DECLARATION
. I hereby affirm that I em Ilconsetl under prwlalons of Chapter B (commencing with Section
WOOD SHAKES ❑
nd l a
7000) of Dryislon 3 of the Business and Profession. Code, amy lrse le In full arca and
affect.
( [(//�rl ^/
WOOD SHINGLES ❑
ate 'Y6 /'7.7—
I-carClose Llc.Number
OTHER (SPECIFY)
" �1301 99
Date Contractor
DERD CL IXJ
OWNER BUILDER DEC's
A /
trainOWNER-BUILDER
hereby affirm Hut am exempt the I -co
Limree Lew ler the allowing reason.
PROPOSED lV _
(Sec. 7031.5, Business and Professions Cods: Any city or county which requlres a permit to
construct, alter, Improve, dandles, or repeat any structure, prior to Its I ursuan, also reproves the
BUILT-UP ROOF
islicensed7000) ttothe provolone
permit to IlaaChapt
44_
of the oerrsuch
of the Law (Chapter Division 3 of the
r9(commtement (commencing
(commencing wlh Section
g
ss and Pr fLkenw
me b st
Code) or Hat he b exempt therefrom and the bash for Na
ase end h
ASPHALT SHINGLES ❑
uto
automation.of 7031.5 fora permit subjects the applicant to
Oblation ica t to
a chril en.lty oWoottonofSeclbn
hundrbyanyappliant
e cMl penalty of not more than INe hundred tldlere (5500)J:
WOOD SHAKES
❑I,as owner of the property, or my employee, with wegas as their sole compensation, will do.
❑
Ne vont and the svucture Is rot Intendad or oHeretl for sale (Sac. 70/4, Burliness anti Protest.
sions Code: The Contractors License Law don not apply to an owner of property who hulas or
WOOD SHINGLES ❑
innol thereon. and who dose such work himself or through his own Mne., ployeprovitletl met
such Improvements we not Intended or offered for sate. If, however, the bu k ng or Improvement
is the haver the burden Net he tla
sold within arta year of completion, owrenbaltler will of paying
OTHER(SPECIFY)IJ /
not bulb or Improve for purpose of sale.).
I,mownerof Neproperty,emextlu elycantrectlnngg wihlfoereetl contractor to cornbud
3� /�.
the prclen(Sec.7W4, Business and ProloWons Code:The Convectors License law does not
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who buds or lmprcl Marson, and who curHwcb ler such projects
with a contractor(s) licensed purauant to the Cmtmdora License Law.
8Yy iG n
❑ 1 am exempt under Bee. ,B a P. C. ler Hae reason
PROVIDE MFGR. INSTALLATION SPECS.
owrwr - Date
APPLICATION DATE
VALUATION
PERMIT FEE
' WORKERS COMPENSATION DECLARATION
-7 '
I hereby affirm under penally of padury we d Ne following Eeclaralon:
willConsent to urmerce
Search fCoc
Building
3700 of 1ha�Laborte
as pprrwked ler by a for the perfor of me wort, for which this
.
perm t I, issued.
Seismic.
❑ 1 hay and will malnhin Workers Compensation Insurence, as required! by Shan 3700 of
her Labor Code, for the performance of the work ler which this permit le Inuml. My Workers
Compensation Insurance Policy
`/
2�O
Total
carrier end number are: -.
Carder Paley No.
PERMIT .AUTHO IZATION -
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
`N.CQ
COMPENSATION INSURANCE
(This aec0or need not be completed If the permit Is ler ore hundred dollars ($100) or Ina.)
I certify that In the performance of he work ler which this permit Is Issued, I shall not employ
- any person in any manner w n to become subject to the Workers' Companseuon Lam of Cell
All roofs shall be Inspected prior to any roofing material being
errma.
. installed. If a roof is installed without first obtaining an
Data Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, after making his CerlNc tte pf Exemption, you should become
Applicant understands and will comply with .all non int
PP P Y PD
subject to the Workers' Compnsetlon prwleans d the Labor Cotle, you must forthwith comply
with such provielons or this permit shall be deemed revoked.
• source regulations. -
I certlty Met l have read this applicallon and state that Me above lnlormetlon is coirect.I agree
to comply with all city and county ordime sand Matetam relating to buaairg mnstructan,and
All roof�coverings to be classor better.
hereby eutborlze repree.nutives of this City to enter upon the above-mentbnetl property ler In.
speWepurpose.
(We)) apnea to save, indemnily, end keep h the•Gry of Cupertino ap Inst Ileblllflee,
y I say way
IudOmgran meta and axpereee which may in any way accrue against sea Gry In domequence
' SIGNATURE OF APPLICANT ATE
ol the gwntlrg of this permit.
PRE -INSPECTION:
PLYWOOD:
IN -PROGRESS: ,
INSP. DATE
'
INSP. DATE
t .
INSP. DATE
TEAR OFF INSPECTION:
BATTENS:
FINAL:
'INSP. DATE -
INSP. DATE
INSP. DATE
NOTE: OSHA AP.PROVED.ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE.COPY