R-6162rail
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OFFICE COPY
PERMIT c r�
R� 6 6 2
APPLICATION FOR CITY OF CUICERTINO- NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
_ REROOF PERMIT (408)777-3M PERMIT EXPIRES IF WORK IS NOT STARTED
- - WITHIN 1 W DAYS OF PERMIT ISSUANCE OR
' 1 W DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
I
'OI / ADL -
RESIDENTIA COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
yes -1 understand that a Class A
YES ❑".1=*
NAME 111Jj I.L/yi')a �
roofasse *is required.
NO ❑ Imil I.C.B.O. B
-1 2 �-A
EXISTING ROOF COVERING -
ADDRESS -In 9 '6( f'Q <
-
'
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOR'S/ /
i
J
TO BE REMOVED _ TO BE RETAINED
'NAME 1`)s (r -S
TYPE OF ROOF COVERING
ADDRESS
CITY 8 ZIP
EXISTING
�t
PHONE �7!l :359`12_33
❑
BUILT-UP ROOFLICE
NUMBER 195.3 vil
ASPHALT SHINGLES ❑
/
-LICENSED CONTRACTORS DECLARATION
I hereby affirm met I em licensed under previews of Chapter a (commencing whin Section
WOOD SHAKES
7000) of Division 3 of the Business and Profeaebns Code, and my, license is In full tome most
effect.
/n• ������
�T_
WOOD SHINGLES ❑
License Gees ` Lk. Number _
OTHER (SPECIFY ❑
Date Contractor - -
O`t BUILDER DECLARATION
1 hereby that I em exempt from the Cantny
from License Lew for the Cres
PROPOSED
treason.
(Sec. 7031.5, , Bu city e permit to
Business and Professions Code: Any clry county which requires a permit
-
or ep pr
priorto Its beuenos, also Me
, also
BUILT-UP ROOF
applicuct,oher,Improve,demolish,orrepeatenystructure,
for each permli to Ole a signed to the pmvlsloos
Dceoss 9(comm 1hetJtI%M 1 nee0
of me o r 000rot 14D
of the l and
Lew (Chapter a (comma with u�ippplbiT-the be
Buelneea entl Prolesekxt Code) or that M b apt refroaf ertE�lhe be the
ASPHALT SHINGLES .
memphon. Any vblatlon of Section 7031.5 by arty tlor r M 1
a doll psnehy of nct more Man fW¢ hundred dol (000).): -
i wages
WOOD SHAKES -❑
w Mdr sola compensation o
me work, AM Me structure Is not Intended Or ofkr sale (Smc. 7014; Baa{my, and -
❑I,mowner of the property, Or my enmplayeost'ra.
slonsCode: The Contractors License Lowtloeepplyfoanowndr!cf,properrywho I r
Inprovea Hereon, who dose work through his
WOOD SHINGLES ❑
and each own empkryaes�provl el
such Im rOvenrent are rot InlerWed or uftrM to llhawwar, He bulgl or I �_y tP^g nRL•^y
Is sold within one year of completion, Me "nor dgr will have the burden of proving th e d
OTHER (SPECIFY)
not bulk or Improve for purpose of sale.). dy
E] 1, as owner of the property, em exduelveyc 1 d
the project (Sec. 7044, Busirroes entl Professions Code: he Contractor'e UBR 1
PROVIDE LC.B.O. REPORT NO.
appy to an owner of property who builds or Improves thereon, and who contracts br each project
/
with a centra oor(e) licensed pursuant to Me Contractors license Law.
'S
PROVIDE MFGR. INSTALLATION SPECS.
❑ I am mewl under Sec. ,B & P. C. for this reason
Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
-
I hereby affirm under penalty of penury we of Me tdlowing dederahor:
❑ I have and wlll maintain a Cori of Consent to sell -Insure for Workers Comperuatlon,
Building
as provided for by Section 3700 of the Labor Code, for the performance of the work for which mle
r le teued.
have end.11 mountain Workers Compensation Insurarrce, es required by Section 37W of
/�O
I
$eISR11C- /r
c
r Code, for the performance of the work for which ma permit Is Isauotl. My Workers
7 0
omeartet on naj�f� nce unlet and Policy number are:
Total f r 1
K3 �3
PERMIT AUTHORIZATION
DATE
Gamler� (/Q 1%Q �%Q. POIIcy No We -2d9
- CERTIFICATE OF EXEMPTION FROM WORKERS'
-
T
COMPENSATION INSURANCE N.C.0
(This section need not be completed It the permit is for arra hundred dollars ($100) or lees.)
I certify that In the performance of the work for which His permit Is Issued, I shall not employ
any person In any manner so as to become subject to the Worker' Compensation Laws of Cell.
All roofs shall be inspected prior to any roofing material being
fornia.
installed. If a roof is installed without first obtaining an
Date Appscent
inspection, I agree to remove all new materials for inspection.
you anoad become
, you
NOTIauWeco m ft, after
W ka �koNsora ofeihe Code,
Applicant understands and will comply with all non point
LLaatbeor
to the eC0 you forthwith campy
p p you
with such provlalons or this permit shall be deemed ranked.
sour:, regula Ions.
1 cal lty that I have rend Nt appliutlon and state that me abohm Informal Is correct 1 agree
laws relating to building cwwr,end
to comply with all city end county crounimiaMette tuctbn
All r00}CO r b CI S Or better.
hereby authorize mpresenttives of this city to enter upon the above-mentioned property lot In-
wootlon purposes.
Indemnify entl keep harmless the Cly of Cupertino apeInat Ilebllides,
(We) agree to so".$
Judgments, coat and expenses which may In any way accrue against sold City In coneequerwe
N E OF APPLICAN DATE`
of Me granting of rot pend. -
PRE -INSPECTION:
PLYWOOD:
IN -PROGRESS:
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