R-6598 PERT
APPLICATION FOR CITY of CUPERTINO
NUMBER R- 6598 .
REROOF PERMIT. INSPECTION DIVISION PERMIT EXPIRATION
.(408)777-9228 PERMIT EXPIRES IF WORN IS NOT STARTER
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION..
BUILDING ADDRESS
Sx RESIDENTIAL_>_COMMERCIAL—'OTHER
OVINER'S - "/'� HAZARDOUS FIRE AREA
•F yl�n v r�/1 YES ❑ If yes S I ud*iSeM dre . class A
NAME l.� R a l-- V ti7�71 roof a ertby is ragWred.
- No ❑ west Lc.e.o.r
ADDRESS. C'�Q�E !� EXISTING ROOF COVERING
PHONE U �p�� NUMBER OF EXISTING COVERINGS
CONTRACT S TO BE REMOVEDO
_TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITY aCCZIP EXISTING "
PHONE\ / ` BUILT-UP ROOF ❑
NUMBER ASPHALT SHINGLES
_ LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am nceneed under provisions of Chapter a(commencing with Section WOOD SHAKES- ❑
7000)of Division 3 of the the Bus�eae arrd Professions Code,and my license Is In full lures antl_
�a" WOOD SHINGLES.
License C LIc.Number
License
0gg, �\SO ❑
Date Convenor Fyy � OTHER (SPECT ❑
• OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the COntracuors License Lew for the following reason.
(Sec.7031.5'Business antl Professions Code: Any city or aunty which requires a permit to
anewct,&he,,Improve,damoleq or repair any mrodurs,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
applicant for each permit to He a signed aMtemmt Chet he Ie licensed pursuant to the provisions
of the Contractors Ucenae Law(Chapter g(commencing wiM Section 7000)of DNIalon 3 of the
sions
Business and ProfesCode)or that he Is exempt therefrom and the bele for the alleged ASPHALT SHINGLES
exemption.Any violation d Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dollars(5500).):
C]1,at,owner of the property,or my employees with wages as their ads compensation,will do WOOD SHAKES ❑the work,grid the structure a not Intended or offered for Bele(Sac.7014,Bwlnese and Profes.
shin Code:The Conbedoes License Law does not appy to an owner of property who bulklaor WOOD SHINGLES -
Impro,esthereon,and who does auch work himself or through his own employees, rovided that E]such Improvements are not Intended or oNered for sale.If,however,the bulking or Pmvmmwt
Is sok»iwn we year of completion,the owner-builder will hew the burden of proving that he did OTHER(SPECIFY) El
Wild or Improve for purpose of sale.).
❑I,as owner of the property,am oxdualvey antractlnaa with licensed contractors to construct
t On pproject(Sec.7046,Business end Professions Code:Tre Commences Ucenss Law does not PROVIDE I.C.B.O. REPORT NO,
sporty to an Owner of property who bulks or improves thereon,and who contracts for such projects
with a contmdogs)licensed pursuant to the Contractors License law. - PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B a P C.for this reason'
Ower Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I he Irm under penalty of perjury One of the following declaration: / �s
hew erM will maintain a Cart ficete d Consent to sen-Insure for Workers Compensation, r��yL�� Building
/2
ked for by Section 3700 of the Labor Code,for tin performance of the worx kr which this �pv .
permit a Issued. `1}' Q
711 have are will maintain Workers Compensation Insurance•sa repulred by Section 3700 of ` Seismic
I Labor Coda,for the performance of IN work for which this permit is issued.My Workers / O
Compensa�tion�Ins�ura-rn�ce carter end\Polity number ere: �.L�`A��� ��_(M-`(��l��y��`�..� Total ( 7� .a
Cartier_--c!s it9,A�a — Policy No.1�-�1 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p
(This section reed not W completed If the pemtit Is for one hundred dollars($100)or lege.)
aridy that N the performance d the vork for IOlr Nle permI m IeaueO,I alrall not em kv p�,y�prior to any roofing material being
any person n e manner so as to became subl to the Workers'Cormarrutkn Lowe 01 All roofs shall be ins
fornia. installed. If a roof is installed without first obtaining an
Date Applk:apt inspection,I agree to remove all new materials for inspection.
NOTICE TO AP UCANT: n,after making this Certnkate of E tion,you ah me Applicant understands and will comply with all non int
Ru NOTICE
to the Workere'Compeneetlort ro,'I of the Labor C u must forth h y PP P Y PD
weft such prwWons or thio permit shalPbe deemed rewked. source regulations.
I certity that l have read thio appllcenon antl state that iha eboee nformatlon Is correct l agree
to amply with all cityend county«tllnancea and state laws a aing to bulking coprop tlof ane All f covering to be class or better.
hereby ly authorize all reprssd ccunta of this city to enter upon the above-m Wilding
tl BIMUCty f«In-
spedlon purpoese.
(We)agree to save,Indamnlfy,and keep harmless the cry of Cupertino against Ilabllnes,
Iudpmens,costs and exponse9 which may In arty way accrue against said Gry In consequence
of the gramdng ofthis"emit. SIGNA URE 07XPPLICANT DAT
PRE-INSPECTION: PLYWOOD: I - OGRESS:
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