R-6534 PERMIT R- 6 5 3 4
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT ' (408)Tn-3228, PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN IN DAYS OF PERMIT ISSUANCE OR
190 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL_ C/COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
Q hit YES ❑ R yes-1 understand Met a Glass A
NAME r '_ 1 NO - moot assembly is required.ItrutI.C.B.O.R
S 'h
ADDRESa, q r12 CY EXISTING ROOF COVERING
PHONE INGS
CONTRACTOR'S
NAME NL-y ) b TO BE REMOVEfixtL D TO BE RETAINED
ADDRESS Z �_ � MAY 1 0 19 V I
CITY&ZIP-
. EXISTING
By
PHONE-461A 1 / _ g 4 _ ❑LICE
,
NUMBER `(� ASPHALT SHINGLES LAS
LICENSED CONTRACTORS DECLARATION
I hereby emlrm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ®�
7000)of DMsen 3 of the Business and Professbre Cade,aae my license Is In fua force and '
ems' � r l.l�• �y1 WOOD SHINGLES ❑
Ucerse C —Lb.Number
I-yA�' 1
, ,. 121-G OTHER(SPECIFY) .
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Correctors I-cense Law for the following reason.
(Sec.7031.5,Business and Profsssiom Cade: rAny dry or county which requires a permit to
common,after,Improve,demolish,or repair any structure,prior to as Issuance,also requires Me BUILT-UP ROOF ❑
applicant for such penal Is 9le a signed statement that ha Is licensed pursuant to the proAsi"
of the Commodore License Law(Chapter 0(commencing with Section 7000)of Dhrl 3 of Ifs
. Business and Proleeakxs Code or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violabon of Section 7031.5 by any applicant for a permit subjects the applicant to
a dull penefly of rot more than I"hundred dollen($500).):
I,as owner of the property,or my,employees with wages an their sole compeneaten,will do WOOD SHAKES ❑
the work,and the smudure Is not intended or offered for sale(Sec.7044,Bualness and Proles.
alone Cade:The COMrMora Ucenae Law doss not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who can such work himself or through his own employees,Wovioed that
such improvements are not Intended or offered for who,If,however,the bulling or Improvement '
a sdtl within am year of congledon,the owner-bulkier will have the burden of prodnii that he did OTHER(SPECIFY) ❑
.not build or mnprove for purpose of nab.).
❑I,as owner of Me property,am wMaKely cunmacarq with licensed contractors to consul
Me project(Sec.7044,Bueimss and Professions Colla:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
appy,to an owner of property who Wilds or improves thereon,and who contracts for such projects
with awarectar(s)licensed pursuant to me Contractors Ucense Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B a P.C.for thio reason
owmr Date -
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
'
I hereby allirm under pemhy of perjury,one of the following declaration:
-11 hove and wie maintain a Certificate of Consent to se9.lmure for workers Companeetem Buildlnd 0 7
as prW Wed for by Seofm 3700 of the Labor Code,for the performance of Me work for wt kh Mie O
Permit brie and S� (U Sellsmic
❑I have and Rxill maintain performance Workers f the w rkfor Ireu h th18 ae required by Sadbn 3700 0l
the Labor Cade,for the dof the work for which thle permit Is Issuetl.My Workers / ']
Compenae9on lauronca aMar and Policy number are: Total ( ��
Carrier t Fu t- PdIcyNO. I fZ.�1663— PERMITAUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' -
COMed If me ION INSURANCE N.C100)o `� r—�^
(Thio section need not be cgmpbletl d Ma pevmk le for ane rumored!tldlene($100)on lees.) - � l/ ,�]_J �
I cerety,that In the performance of the work for which this permit Is beuse,I shall not emoy
any porton N arty manner so m to become sub)ect to the Workers'Compemetlon laws l til All roofs shall be inspected prior to any roofing material being
hernia. installed. if a roof is installed without first obtaining an
Date - Applicant inspection,I agree to remove all new materials for inspection.
NOTICsubject to Eh Worms'CComparrrerbo ermlaloele of Certificate you you should become Applicant understands and will"comply with all non point
p you mud shoullth comply
with eudr provlsiorro or this permit shell be call revoked. urce regulations.
I coldly that I have reed ante application and state that do above Informatfon is carrel.I agree
to comply whin a city end coury ordlmmee and state Iowa hotel to bolding construction,and All OVeringSt Class Or better.
hereby authorize representatives of thus any to enter upon be ebo arronaoned property for in-
spection purposes.
(We)agree to se",Indemnify and keep harmless the City of Cupermrn apelret Ilabilltles. S- —
jeiymenta,costs and expenses which may In any way accrue against said City In consequence
of the 9manting of this permit. ATURE OF APPLICANT DATE
. 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.ACCESS TO ROOF SHALL BE PROVIDED FOR.INSPECTION
OFFICE COPY