R-6157 PERMIT R_
APPLICATION FOR CITY of CUPERTwo NUMBER 615 7
- INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT - (408) 777-3228 - PERMIT EXPIRES IF WORN IS NOT STARTED
- WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS -
RESIDENTIAL COMMERCIAL OTHER
OWNER'st HAZARDOUS FIRE AREA .
��� �.� O VES [j , R yes—I understand that aClass A -
NAME .roof assembly is,requited.
NO ❑ Initial LC.B.O.M
ADDRESS S C{�-j'•VI/� `ems - EXISTING ROOF/COVERING
PHONE [ NUMBER OF EXISTING COVERINGS J
CONTRAC R' _ - -
_T TO BE REMOVEDTO BE RETAINED
NAMEz 7•• ..
ADDRESS �f " TYPE OF ROOF COVERING
CITY&ZIP /
/.aa 3 EXISTING
PHONEi/� - !� 33 BUILT-UP ROOF ❑.
NUMBER - ASPHALT SHINGLES
❑ I
LICENSED CONTRACTORS DECLARATION _
I hereby affirm that I em licensee under mo,,dpons of Chapter 0(commencIN with Section WOOD SHAKES
7000)of DlvIson 3 of the Business and Proteealone Code,and my license le In lull once and
aced. C 39 /_ WOOD SHINGLES
Loerue Clem Lk.Number `t' K/ D
Data ContractorOTHER(SPECIFY) DEQ
�i z 8 1998
OWNER BUILDER Dtors License PROPOSED
hereby ,Bu that am exempt from the e: Any ors License law for the requires
rq reason.to
(Sec.70315, ,Improve entl Profedemolish
or re Code: Airy dry or county which re,also a uIrest to
applicant for
such
improve,to His si nropelranyntt that e,prior to He issuance,also re quires the BUILT-UP ROOF B ❑
applicant for each permit to file a signed r 9(co em(commencing
he IslicensedSectio pursuant to the n 3 Of he Y
of the ss(Contraclor'sPro Us'nse Law(Chaplet S(commencing with om and 7000)si for Me 3 of the
• business entl Pmlemkxre Cede) 7Net he Is any applicant
therefrom end the beets for - ASPHALT SHINGLES
exemption.Any f not onm Section 703dr byartyepploa),lionaPermit eubjecta tits epplkent to
e dull penally of at
more than Ove hundredf f (5.500).): WOOD SHAKES❑I,k,owner al he property,or to drop or oee red wages as c.7 Bole compenaatlon,will s. ❑
the wink,and the structure Is not Intended or offered for seo(Sec.]0.0 9or"yentl Proo0-
eloits CodhThe,adwho d License Lawwtlim rotapplytoanamen Wproperty whopuede« WOOD SHINGLES
Improves Hereon,entl who does ouch work edfort or through his Own amplonriot,or provld'd that ❑
ouchd within one year
ere not Intended the
offered for role. ill however,the len of pr or Improvement
Is sold or one ymrofcompo of sthe owner-builder will have the human of proNng that he tlld OTHER(SPECIFY)
not build or Improve for purpose of mleJ.
I,as owner of the property,em exclusMty contracting with licensed contractors to construct
the project sec.70",Business end Profernions Code:The Contradora License Lewtloes not PROVIDE I.C.B.O.REPORT NO.
appy to an owner of property who bullds or Impro tae thereon,and who contracts or sun projects
with a compactor(s)Ilcerued pursuant to the Convacrors Ucenee Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,B&P.C.for this reason
owrrer oats
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
'
I hereby affirm under penalty of perjury one of the following declaration: - Q 7
[_II neva and will maintainse
a cemacate of Concept to seWlnaere for workers Compensation, Building
as provided tar by Section 37W of the Labor Code,for the performarca of the work for whop this
penin Ila Issued. '5S
!�(J
❑ have and for the peon Workers f the w eelon Insurance,m required Is i by Becton Worker7DO of's
A'VA �-• TotaSelsl
the Labor code,for the performance of the work for which Ugs parmH le issued.My Worxera S 000 Total g7.5a
Comp' I2figan�c/e carper and Poy�nupiber �a2��
Center @►�CIIF'� ITOFEEM Q1�OMNo. I PE ITAUTHORI ION DATE
CERTIFICATE EN ATION INSURANCE
FROM WORKERS'
COMPENSATION INSURANCE N.C.[]
' (This section need not be completed H the permit is for one hundred dollars($1(X)or IaeeJ - � !/
I cantly hal In the performance of rho work for which thb permit Is Issued,I shell nal employ
any person In any manner eo m to become subject to he Workers'Compenmton Lewy of Can All roof��� shall be.inspec prior to any roofing material being
fouls. ins Ed If a roof is installed without first obtaining an
oat' Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,after making this Certificate of ExemiI you should become q Ildant understands and will comply with all non point
suoject to the Woohm,'Compenmtlon pptovialons of the Labor Code,you must forthwith campy ' Applicant p Y p
with such provLdons or this permit steel,be tleamed revoked. source regulations.
I certify that I have read his application and stale that the above Inclination Ie correct I agree -
-.to comply with all city and county ordinance'and state laws relating to bulking construction,and All roof Coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mantldned property or In-
spection purposes.
(We)agree to rove,Indemnify and keep harmless the City of Cupertino against IlabWlim,
judgments,costs entl expenses which may in any way accrue against sold Cry In consequence
of the granting of this permit. SI RE 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY