R-6252 PERMIT R_ 6252
APPLICATION FOR CITY OF CUPERTwO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-9228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS I =
RESIDENIIALL __COMMERCIAL OTHER-
OWNER'S. HAZARDOUSPRE AIR
^ ^ - YES ❑ If yes—1 understand tat a Cla4vA
NAME�r✓�I ��LL roof essemhly is required. • .
NO Irtigal ` LC.B.O.B
ADDRESS U ,o �r�'�i;aeEXISTING ROOF COVERING
PHON ,• NUMBER OF EXISTING COVERINGS '
CO O '
NAME`L� A�l e9 r [�j('D n5 BE REMOVED - I TO BE RETAINED
ADDRESS {..11 _ TO_ TYPE OF ROOF COVERING
CITYaZIP ��53 951
EXISTING
PHONE 1 I — �" S U _ BUILT-UP ROOF ❑ .
LICENSE - �� 77 ��'�
NUMBER ZW lo ASPHALT SHINGLES
DCENSED CONTRACTORS DECLARATION
Ihsreby affirm that I em Ibensed under provisions of Chapter g(commencing with Section COD SHAKES
7000)of Dldslon 3 of the Buslneaa and Professors Cade,end my license le In full force and
effect, o,
Wil- '41S2o / v ❑
License Close Llo.Number � '
Date Contractor. r2�� ✓�_ JTHER (SP� /4 ❑
did from Me LDER DEc QN PROPOS �/�
hereby efkrm that em exempt lion the Contractors ucerse Lew for the blowing reason.
(Sec.7031.5,Business and Proleealone Code: Any city or county which requires a permit to
construct.atter,Improve,demdlen,or repair any structure,prior to its leauance,also requUee the BUILT-UP ROOF
applicant for such permit to Iib a signed statement that he Is licensed pursuant to the provisions
01 the Contractors ucensa Lew(Chapter 8(commencing with Section 70001 of Olvlelon 3 of the -
. Business and Professions Code)or that he is exempt therefrom and the mels for the aseged ASPHALT SHINGLES
exemption.Arty Oblation of Section 7031.5 by any applicant for a permit a Jects the eppllcant to
e dull penalty of not mora than five hundred dollars(5500).):
❑1,as owner of the property,or my employees with wages ss thelreob compritaetlon,will do WOOD SHAKES ❑
the work,and the structure le rot Intended or offered fol sale(Sec.-70,";Business Ono Proles-
alone Code:The Contractors License Lew does not epph,t6 an owner M pioperty wpo bunds or WOOD SHINGLES , E]Improes thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.pry however,tli�bullding or Improvement -
isaddwithinmeyear ofcompletion,the owner-bulkier dl havetheboanoi ngthathedm OTHER(SPECIFY) ❑
not build or improve for purpose of sal )
01,ae owner of the property,em exclusimly contract with acensed contra construct
the project(Sac.70",Business and Professions tele Code ContradLicense'L{v does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property what Wide or Improves the n,andwhro ntracKfor proects
with a contractors)Iloensed purnt suato the Contractor nee La
❑I am exempt under Sec. eP.C.br Breason PROVIDE MFGR.INSTALLATION SPECS.
Owner APPLICATION DATE VALUATION PERMIT FEE
WORKER'6 COMPENSATIO ECLARATAT
I hereby affirm under penally of perjury one of the fol ng d}�¢�00o=r 7 A_"�
❑1 have and will maintain a Certificate of Consent to If-IisJra,Yp Worger'�08 ensenon, Building AQ 7L 0
as provked a by Sedan 3700 of the Labor Cada,forth which this l /i's��
per01 Is tissued. � e gW1k r/(J Seismic B
❑I have ark will mountain Workers CompenmetlOn Insurance,as required by Section 37OO of
the Labor Cade,for the pertormerXa of the work for which this permit le blued.My Works(((e ' xO
compensa'tbn Insuran�ce^carrier ark Policy number are: J�� Total /ham
Carrier 3rd- �"�^'� Policy No. w�—x fol PERMIT AUTHORIZATION - DATE
CERTIFICATE OF EXEMPRON FROM WORKERS'
COMPENSATION INSURANCE N.CQ - /•
(This section need not be completed if the permit Is for one hundred dollars($1 N)or loss.) /, 6
1"Mty that In the performance of the work for which this permit is Issued,I shall Trot empby
any person In any mariner was to become subject to the Workers'Compensation Lam of Cali- All roofs shall be inspected prior to any roofing material being
fornla. n installed. It a roof is installed without first obtaining an
Date Applloant j - ��'" inspection,I agree to remove all new materials for inspection.
NOTIC ener mall ng Certificate of Exemption,you should become Applicant understands and will comply with all non point
eubled to the Workers'Compensation prods g of the Labor Code,you must forthwith compty pP P Y P
with such pmvlslws or this permit shall W deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information Is conect.i agree
to comply with all city and county ordinances ark state laws relating to bulking conenuctlon,and All roof coverings to be class"C'or better.
hereby authorize repreaentattm of this dry to enter upon the abova-mentbnatl property fa In-
spec0on purposes. t�
(We)agree to save,Indemnify end keep hermle.5e the City of Cupertino agalnat"bigots. „
judgments,costa end expense which may in arty way ecaue against said Gty 1n corsequerKe NATURE OF APPLICANT [DATE
dine grahtfingperML
-
PRE-INSPECTION:CTION: PLYWOOD: ( �/ rIN-PROGRESS:
INSP. DATE INSP. �DATE /�o/ ��1p 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