R-6415 NUMBER 6415
ATION FOR CITY OF CUPERTINO ERMIT R
�■ INSPECTION DIVISION PERMIT.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.
FRURESS - -
�8
G ,RESIDENTIAL ' COMMERCIAL OTHER
OWNER'S J , HAZARDOUS FIRE AREA
NAME �"� VES ❑ It yes—I understand that a Clew Aas -
rool assembly is required.
Initial - I.C.B.O.R -
ADDRESS (O /Ci �C//dig �—/ 'EXISTING ROOF COVERING
PHONE 0 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S '
- TO BE REMOVED �.TO BE RETAINED
NAME
ADDRESS .y n( // TYPE OF ROOF COVERING
CITY&ZIP�Sd
/,c"�� EXISTING
PHONE ° D6 c17 BUILT-UP ROOFLICENSE
❑ '
NUMBER W
NUMBER J — 73 ASPHALT SHINGLES
UCE SED CONTRACTORS DECLARATION -
I hereby affirm that I em foramad under provisions of Chapter 8(commendnp wnh Section WOOD SHAKES
7000)of Dlvil lou 3 of the Business end Professions Coce,and my license b In full force and -
effect. WOOD SHINGLES -
License Clava� Uc.Number 'S ^ 3 ° .
Date 3 . P f-,5 Conirea« OTHER(SPECIFY) ❑
OWNER-BUILDER DE n PROPOSED
I hereby affirm that I am exempt from the Convectors Upon hr the following reason. / i >
(Sec.7031.5,Business and Professlana Code: Any dry or y which requires e permit to 7(/
construct,alter,Improve,demolish,or repair any structure,prior to its lawerne,also requires the BUILT UR ROOF
apoloam for such permit to file a signed stabment that he Is licensed pursuant to the provisions
of the Contractors Ucenae Law(Chapter a(commencing wlih Section 7000)of Division 3 of Ne
• Business and Professions Code)or Met he Is exempt therefrom and the basis for the avol ASPHALT SHINGLES
exemption.Any vbletlon of Section 7031.5 by any applicant for a penult subjects the applicant to
e dull penalty of not more than five hundred dollars II'sooW:
[31,es owner of the property,or my a.0 wages w Meir sale compensation,wYl do WOOD SHAKES El
me work,and the shucture U not Inten or o e Sec.7044,Business and Proles.
almaCme:The CmimaoraLfoensa , not tom ny who wiles or WOOD SHINGLES ❑
Improves Mereon,and who does such r lmee 7 gh his provked that
such Improvements ere not Intended 1 ad for la. r t buil improvement
Is aaM whin one year of completion, 'towner-wader will neve men ng that he did OTHER(SPECIFY) ❑
no,bull or Improve for purpose of �(
A I
❑I,as owner of Me property,am Iueharyect(rg wTlh" co to crostruct
Me project(Sec.7044,Business an mbserons CotletTherCprltTdaa law does not PROVIDE I.C.B.O. REPORT NO.
appy,to an owner olproperty who 5 o Irl a Mereon,anti wAK'iiTTT,000nnnI orsumprolms
wWeconvedorte)Ikansedpursu pq Me Contractor's lienee law. PROVIDE MFGR. INSTALLATION SPECS.
am exempt uMer Sec. LS ,B .for Mk reason
O� nrhrAPPLICATION DATE .VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARAn
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Canaem to solfansure for Workers Compensation, BUI din
as provided for by Sadkn 3700 of tIe Labor Com,for me performance of the work for which MIs g '
permit Is LSC. a /7 �7Q O�O -
❑1 have entl will rna ala W er'e Compensetlon Ireurence,es required by Section 3700 of 5 �j / Seismic
the Labor C d r pe ace of the work for whfoh this permit Is Issued.My Workers 47F�o
Compeneatlo s is
and Polley number are: Total
Carder— PERMITAUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N(1 o ��� �•a
(This wctlon need not be cartWleted H Me permit le for one hundred tlellere($1(1 or lees.) lrr
I certify that In me perlorm,unce of the work for which this permit is issued,I shell not employ
any person M any manner so as to become subject tone Workers'Compensation Laws of call- All roofs shall be inspected prior to any roofing material being
fornix. - installed. If a roof Is installed .without first obtaining an
Dab' App soon inspection,I agree to remove all new materials for inspection.
NOTICE TO APPUCANT: If,after making this Certificate of Exemption,you shouk become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP P Y P
with such provisions or this permit shelDbe doomed revoked. sour gulations.
I mortify Met I have reed this application ark state that the above Information Is correct.)agree
,o comply with all city and county ordinances and state laws relating to bullcmatruction,and roof coverings to be class' Or better.
hereby authorize revesenoftlres of this dry to enter upon the above-mentk n d property,for In- -
sp ctimWrt)agreeaes. f '7
(We)agrees ease,expenses
and keep harmless the Cly of Ct sad!C against Ilabllltlee, 7 /�
lu menta,woof and expenses which may In any way emus against sok Gry In cmaequerrce
. d t e grenmg of his gemma. -87NATUW 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