R-6236 PERMIT
�— NUMBER R— 6236
`�- APPLICATION FOR cNS of I Nl'E DIVISION
INSPECTION DIVISION PERM1r EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS ^
14ES5-1 (/jl \J J RESIDENTIAL )/' COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class A
NAME root assembly Is required. -
. NO ❑ ititial I.C.B.O.N
ADDRESS/ �.-.7EXISTING ROOF COVERING
NUMBER CIFEXISTING PHONE ` 2 S - / NG COVERINGS /
CONTRACT
O '
TO BE REMOVED TO BE RETAINED
NAME '
ADDRESS�.� (1 _ _ p 9�(5•G TYPE OF ROOF COVERING -
CITYBZIP ll'1 o—,z
'/ ,/ EXISTING
PHONL45/je) '9Y — 9y1I BUILT-UP ROOF ❑
LICENSE ' /
NUMBER o / ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm Met I am'Incense i under provisbrm of Chapter B(commencing with Section WOOD SHAKES
7000)of DII 3 of Me Business and Profession,Code,and my license Is In full(once and
effect. -
�•z[! WOOD SHINGLES ❑
License Clear- Uc.Number • /
OTHER(SPECIFY) El
"Connector r
OWNER.BUILOER DECLARATION Z PROPOSED
I hereby allirm Met I am exempt from the Contractors License Lew for the bllt Mrg reason
(Sec.7031.5,Business and Professions Code: Any city a county which requires ape
construct,after,Improte,demolish,or repair any structure,prior to its Issuance,at"requ e e BUILT-UP ROOF ❑
eppticent ler such permit to Ne a elgnetl statement that he is Incensed pumuenl to Ma or
of the Conhenar's License Lew(Chapter a(commenting with Section 7000)of DlNslo t /
Dueness and Professbrre Coda)or Met he Is exempt therefrom and the basis for th egad ASPHALT SHINGLES 11�
exemption.Any violation of Sectictn 7031.5 by any applicant for a permit sub jactaMa applicant to
a diff penalty of rpt more then five hundred dollars($500).): HAKES❑I,es owner of the property,or my employees wIM wages u their acts compeneatlon,will do HAEl
the work,arM tine structure Is not Intended or offered far We(Sec.70/4,Dual and Profen-
-
some Code:The Contractors Ucense Lew does not appty to an owner of property who Win or WOO SHINGLE$
Improves thereon,and who does such woes himself or through his own employees,proNded Met ❑
ouch Improvements are rpt Intended or offered ler sale.If,however,the Wilding or Improvement
Ie,old within one year of completion the owner-Wldw will have the Wncon of proving that he db OTHER(SPECIFY) ❑
not build or mgtrPm ler purpose of sale.). - - -
❑I,u owner of the property,em exclusively cormadlng with licensed contractors to conelnpt
ee
Meprolml(3 .7044,Bueloeeeend Professions CWe:The Contractors License Lawdoe5 not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,aro who contracts or ouch projects .
with a contractor(s)licensed pursuant to the Centracors License Law. - PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B 6 P.C.for MIs reason
OwnerDate APPLICATION DATE VALUATION PERMIT FEE
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the folbwlrg declaration:
❑ ave /�
1 hend wit malmain a Certificate of Consent to sed-insure ler Workers Compensation, . Building/_Z
as provided ler by Section 3700 of the Labor Cade,lework le
r the performance of the r which this g
perm Is Issued. �� 700 Seismic /20
ve eM will mebteln Workers Cumperwatlon Insurance,ae required by Section 3700 of
r Code,for the porformence of the work ler which MI5 perrut Is Issued.My Workers
perasibnlyeurarpe cgrder entl icy numberere: 1,, K'' Total /-6 r 2a
Canter //�` Policy No. PERMIT AUTHORIZATION PATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CL]
(This section need rot be completed If the permit Is for one hundred!dollars(5100)abee.)
I conity,that In the performerpe of Me wank for which Mie permit is Issued' shall not am toy
am poison In Try mamer so ae to become sublocl to the Work ompensedm Lowe of Dao- All roofs shall be inspected prior to any roofing material being
fornix. installed. If a roof is installed without first obtaining an
Data Applican inspection,I agree to remove all new materials for inspection.
subject m the IL Wor�kere Compennsadon prkoWelm,of the unis 1e code,you mus fa 0hymnalftWid°eC0«npmlya Applicant understands and will comply with all non point
with such pno rftuons or this permit shall be deemed revoked. source regulations. .
I certify that I have read this application and state that the above Information Is correct.I agree
to comply MM all city end county ordinances and state laws rousting to building construction,and All roof Coverings to be class Or better. '
hereby authorize reprasenustives of this city to enter upon Ma above-mentioned property ler in-
ep )
(WerNepurposes.
)epee to,eve,Indemnity and keep harmless the CNy of Cupertino egainat IIabIINes, - �• 3.7
Judgments.octets and expeness which may In any way accrue against veld Clry In consequence
of the grunting of this permL SIGNATURE OFAPPLICANT ATE
PRE-INSPECTION: PLYWOOD: JN-PROGRESS:
"INSP. BATE 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