R-6087 PERMF
APPLICATION FOR CITY OF CUPERTINO
NUMBER R— 6087
INSPECTION DIVISIONPERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
o fill 2A Q) O V\ y
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
L� 1 YES ❑ If yes—I t2ldersWac that a Class A
-
NAME 1_�' x I r-,-, \ ��`Q.�y roof assembly Is required
I NO ❑ Initial. I.C.B.O.P
ADD RESS �0 64- -'-c�— 4. . �(1-�ca� � EXISTING ROOF COVERING
PHONE .6 s 6 `'�
_ `� l 6 � 8O Q NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME P' lJ2J
ADDRESS -
TYPE OF ROOF COVERING'
L$S��iS SISr .. .N II
CITY 6ZIPAl ING
''�� Q - EST '.
PHONE( t $V / 7 —�`S0 d BUILT-UP ROOF ❑LICENSE .
NUMBER 5.20 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION -
I hereby affirm that I am Jlcensed under provislons of Chapter 9(commencing with Section WOOD SHAKES
]000)of Dlvlelon 3 of the Bualness and Profes6bne Cade,and my license Is In full force and
BHBWOOD SHINGLES El Clear Lk.Number �`-' `" -
Oeto �3 I�9 Coal bar �� OTHER(SPECIFY) ❑ -
UYNER the Gang cfo Ls TwN PROPOSED
hereby affirm that am exempt Iran the Code: Anytory Lkenae Lew far the uires a retaon. -
(Sec.]031.5,r,Impose edea Pros,or r ipitanAny city or county,which requires a permit to
construct,eltes Improve,demolish,a signed
or repeat any ntmdure,prior m Its Issuance,also requires the BUILT-UP ROOF ❑
of the Co foretch permute La aChapt statementthat he Islicensed pursuant mthe provisions
the
of the Contractor'sProfessions
License Law(Chapter a Is axe rip wand Section]000)of D1or Me 3 of the ry
• Buelneee end Proleeelone Cotle)or that he Is exempt Marelrom and the heals for the allege0 ASPHALT SHINGLE /��I''
exemption.Any Notation of Sactim 7031.5 by any applicant for a Permit sub)ecis
a cM1 penalty of not more than five hundred dollars(5500).): . WOOD SHAKES
L]1,as ownerof the property,or my employees with wages ersole eatlon, tlo
the work,and the structure Is rot Intended or offered for sale ,0,, pa e-
Wons Cade:The Contractor's License Lew does rot apply to er of opertywho burde or - WOOD SHINGLES/
Improves thereon,antl who tlaea such work Nmsed or through employees,pr
suM improvements are not Intended or offered for sale.If, he gp��p�pp ootr��m
Is sola wltMn erre year of cmnplenon,the owner-Oulloar will he rdploMSg M, OTHER(SPECIFY)
not bulla or Improve for purpose of sale.).
C]1,as owner of the property,am excuaWly contracting with l need contractors to construct
the project(Sea.70",Business and Professions Cade:The rectora Liberals Law dove not PROVIDE I.C.B.O.REPORT
appy to en owner of property who bullas or Improves thereon,a v�g "c1!8fw such
wlih a mntracrogs)licensed pursuant to the Conimaore Ucen 4B�t PROVIDE MFGR.I NSTALLATION ECS.
❑I em exempt under Sec. P.C.for Mil rose.
owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury we of Me following declaration: p
❑1 haya and Oil maintain a Certificate of Consent to self-Insure far Workers Compensation, Building'/ 17
as provded for by Section 3]00 of the labor Code,for the performance of the work for which fire -� l�/�^a
penJt le beued. / C.N
have entl will maintain Workers Compensation Insurance,re required by Section 3700 of Seismic ;s
Ih Labor Cotla.for the performance of the work for which MIs permit is issued.My Workers
Compensation Insurance center and Policy number are: ,\t Total T!/
Csrrler ST/LT£ PolbyNo. `� PERMIT'AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NCQ
(This section need not be completed it the permit is for one hundred dollars($1 W)or less.) 3
I cattily that In Me performance of Me work for which this permit U Issued,I shell not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cell- All roofs Shall be Inspected Prior to anyroofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Appdbant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after mating MIs Certificate of Exemption,you should became Applicant understands and.will Comply with all non point
subject to the Workers'Compensation provisions of the Labor Coal you must forthwith comply
with such provisions or this permit shalC W deemed revoked. Source regulations.
I bevy Mat I have read this application and state that the above Information is coned I agree
to comply Mth all cfy and counry.dinences and state 1201 relating to Whiting construction,and All roof coverings to be class-O&rbetter.
hereby authorize representatives of this city to enter upon Me abo a rnontlonetl property for In- n /l 3/ g
epeWe)agree to S "G7CG7
(Wel agree to save,ibe Indemnify and keep h any
way the Cary a st saidCuiperldhoCi against IIebIlHlea,
Judgments,colon and experael whlU may In any way accrue against vela Cly In caaequenca
of oho granting of this permll SIGNATURE OF APPLICANT -DATE
PRE-INSPECTION: PLYWOOZ. IN-PROGRESS:
INSP. DATE INSP. DATE " INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DAT 17 INSP, DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY