R-6565 PERMIT R_
APPLICATION FOR CITY of CUPERTINO NUMBER 656
5
INSPECTION DIVISION PERMIT EXPIRATIONREROOF 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
RESIDENTIAL COMMERCIAL OTHER
OWNER'S _ - HAZARDOUS FIRE AREA
YES.❑ If yes-I urdamifto d that a Claws A
NAME rod essemby Is required.
l/ NO Initial i.C.B.O.M
ADDREss EXISTING ROOF COVERING
S. / NUMBER OF EXISTING COVERINGS
PHONE (O
CONTRACTOR'S
NAME- +TIS7�C2 - TO BE REMOVED / TO BE RETAINED
ADDRESS ,r7 f Z ��Nis/� .��� TYPE OF ROOF COVERING
CITY&ZIP d' G / EXISTING
PHONE f BUILT-UP ROOF ❑
NUMBER S _ x� - ASPHALT SHINGLES ❑
LiCENSED CONunder
pr CTO s of Chapter
1 hereby islo n trot I em sn,ass under lessors W Chapter a(commencing In with Section WOOD SHAKES]
7000)of DNWon 3 0l the Buelrose en0 Pmseelone Catla,enemy Ilcarue le In lull lone site
a"act pWOOD SHINGLES ❑
License Clave Lk.Number
Dab — Can aeon OTHER(SPECIFY)
OWNER-McConBiDtor'sL PROPOSED Q
1 hereby al Bu that Lem exempt from the Connectors L sa Lew for the mitesfollo-Mng reason. D
(Sec.]0315,Business and Pmbeeloria Cade: Airy cry or county which requires a permit b
aprneWCiorsr,Improve,dfile a a,oralstatrrystructune,prior to IbIssuance,talsoap"Wthe BUILT-UPR
applicant Co ion such permit a file a(Chapter
r 9(comm"na that he Is in Section
pursuant ro tiro prW of the 1, n 0 1(�
of the ss and Contractor's License Lew(Chapter h Is ex(command flet Section]000)of for the ale the �p�I1�IL1r /� . 1x7❑
exemption.
end violation of Code)or that he le exempt therefrom and the bees for the eloped ASPHALTS GLCJ
a cixft en.Anyf mtmnof$actio 7031.5 unbyelrysPdicent bitaPermit subjects the applicant to
e gull Penalty of not more then,or y ompfdred ,&&ii (ff age
❑I,k,and
er the structure
I not I my Intended
or offered for Is as their 44,Ple compena and!will clorotes- WOOD SHA - ❑
Me work,entl the sirucmre le not Intended or offered for sale(Sec.]044,Business eM Proles- / J
alone Coce:The Contractor's License Lew does not apply to an owner of property who bustle or WOOD SHINGLES ❑ T r
Impmvee thereon,entl who does ouch work hlnwe f or through his own employees,provided That ///(�
such improvements are not Intended o offered for sale.If,however,the bullding or Improvement OTHER
7 / 5
Is edit within one year of completion,the owner-builder will he"the Wrden of proNng that he dd OTHER(SPECIFY) .❑
not build on Improve for purpose of sale.).
❑I,as Donner Dftloproperty,amexduslvetyro tmotin withllcane¢dmntnectonetoconstruct 1
Ise project(Sec.7044,Business and Professional Codea°he Contractors License I-aw ease not PROVIDE I.C.B.O.REPORT NO. J
appy to an owner of property who Wilds or Imprcvss thereon,end who contracts for auch projects
with a aonvacq«(e)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. .B 6 P.C.for the reaem
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury ane of the Miming declaration:
1 he"and will maintain a Cenikcete of Consent to salt-insure for Workers Compensation, BDIId Ing I Tr?-ou
as pmvlded for try Section 3700 of the bar Code,for the performance of the work far which this
permit Is Issued -
❑ have end will mala re Compensation Irt9unernGe,as required by SeMon 3700 W
—�j •FOU,G)!j Seismic A•`I o
_the Labor Cade, or nce of the work for which this permit Is Isauetl.My Workers
Compensalbn r entl Policy number are: may./ Total ' r'/V
Carrier � Policy No. 90�(��/ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' ,
COMPENSATION INSURANCE N.CC
(This section need not be completed r the pe h s bit one hundred dollars($100)or less.) /rte- ry �� s Z(.y�(
certlly that In the padarrnanca of the ono r Vch ihla permit Is leauetl, shell not a Ivy rJ
arty person In arty manner w ae to becom subl I the Workers Compensation a f All roolin shall be inspected prior to any roofing material being
fomb. installed. If a roof is Installed without first obtaining an
Deb j "� AnNir inspection,I agree to remove all new materials for inspection.
NOTICE TO APPUCANT: It,after making this ciftiriol Exemption,you should become A II U derstands and will comply with all non int
Subject to the Workers'Comperwatkrn provbkxa Lobo Code,you must MVrWth comply pp p y
with suctr provisions or this pemtlt shale"dee revoked. sour rag BtlOn$.
I tardy,that l he"bad this application and to that the above lnbrmetdn is connect.l agree
to comply with all city and county ordinances and state laws relating to building construction,and All oof cc ngs be class"C"or better.
hereby authorize repreeentatkes of this city to enter upon the above-mentioned property for In. -
spectlonpurposes. 5 //
(We)agree to sass,Indemnity end keep harmless the Cly of Cupertino agehnt IsbllWee, P�
judgments,coats and expenses which may In any way accrue against veld City 1n consequence
of the granting of this permSIGNATOR APPLICANT DATE
it.
. PRE-INSPECTION: PLYWOOD: - IN-PROGRESS:
INSP. r 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