R-6685•
PERMIT R- 6685-
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXP I RATIO
- REROOF PERMIT .. (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
.. - WITHIN 190 DAYS OF PERMIT ISSUANCE OR
190 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS - -
-
/' 7y67
'till
RESIDE NTIAL�COMMERCIAL "'OTHER
OWNER'S If -
.HAZARDOUS FIRE AREA
- YES ❑ R yes - I understand Mat a Class A
NAME I'lero �% CO
root assembly s required.
NO ❑ Inal l I.C.B.O. N
J
EXISTING ROOF COVERING'
ADDRESS G3, "e 'd.,I
PHONE �p .� y5'rG
^,
NUMBER OF EXISTING COVERINGS
CONTRACTO S
TO BE REMOVED - y TO BE RETAINED
NAME
ADDRESS
��!
TYPE OF ROOF COVERING
IP
CITY & ZIP—
r. -
O
PHONE •7OS^pZ75U^Q , -
PHONE'�,; F
BUI T -UP ROOF ❑
1LICENSE.
NUMBER
PHALT SHINGLES
LICENSED CONTRACTORS DECLARATION -
I hereby affirm that i am licensed under provlsims of Chapter 9 (commencing with Sectlon
SHAKES
7000) of Division 3 of the Business and Prolesslons Code, end my license Is in full force and
.�
effect.
/%�'7 a/�J
-
W06 GL❑
License Clese�L� Llc. Number
y_ QOTHERS
) �Q�❑
Date Con or
,��
U--1,
OMER-BUILDER DECLARA N
D
I hereby affirm that I am exempt from the Contractor's Ucense Lew for ma following reason.
,PROPOSED' .
(Seo. 7091.5, Buslnees and Professions Code: Any city or county whlch requires a permit to
construct, alter. Improve, demollsh, Its Isauence,
J V L 999
JUL999
cr repelr any structure, prlor to also requires the
Pa
BUILT-UP ROOF
applicant for such permit to file a signed statement that he licensed pursuant to the provisions
-1
of the Contractor. Llcanse Law (Chapter 9 (commencingg with Section 7000) of DhAslon 3 of the
Business and Prolaselons Coda) or that he is exempt therefrom and tro basis for the alleged
ASPHALT SHINGIL
exemption. Arty violation of Section 7031.5 by any applicant for a permit subjects the applicant to
y
a c[Al penalty of not more than five hundred dollars
❑I, as owner of the property, or my employees with wages as th¢Ir-sole compensator, will do
WOOD SHAKES
the wodc, and the structure Is not Intended or offered for sale (Sec. 7044, Buslness and Profes-
elope Code The Contractors License Law does rot apply to an owner of property who builds or
WOOD SHINGLES ❑
Improves thereon, and who close such work himself or through his own employees, provided that
such Improvements are not intended or offered for sale. If, howayer, the building or Improvement
lasold within ono year of completlon, the owner-bullder will have the burden of proving that he did
OTHER (SPECIFY) ❑
not build or Improve for purpose of sale.).
❑ I, as owner of the property, am exctushisty contracting with licensed contractors to construct
the protect (Sec. 7044, Business and Professiorha Code: The Contactors LKshise Law does not.
PROVIDE I:C.B.O. REPORT NO.
apply to an owner of property who bulkls or Improves theral and who contrecle for such projects
with a contractor(a)'licensed pursuant o the Contractors License law.
PROVIDE MFGR. INSTALLATION SPECS. -
❑ I em exempt under Sec. a & P. C. for this reason
.owner Date -
-
APPLICATION DATE
VALUATION
PERMIT FEE
' WORKER'S COMPENSATION OECLAFiAT10N
I hereby affirm under penalty of perjury one of the following declaration:
❑ I have and will maintain a Certificate of Consent to seit4nsure for Workers Ooopensetion,
Building
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
pIs Issued.
Yhave and will maintain Workers Compansaton Insurance, as required by Section 3700 of
6,
seismic
tLabor Code, for the performance of the work for which this Permit Is Issued. My Workers
Compensation -
-
Total
Insurrance carder and Policy number are:
,,{�
Carder ST,T-0 ��� - Po I" No..4WA
PERMIT AUTHORIZATION
DATE
CE TIFICATE OF EXEMPTION FROM WORKERS',,
101
COMPENSATION INSURANCE N.CQ
(This section need not be completed If the permit Is for one hundred dollars ($1N) or lase.)
// Z
I certify met In the perormance of the work for which this permit Is Issued, I shall not employ
All roofn s all be inspected prior to any roofing material beft
any person In any manner so a, to become subject to the orkere' cemperaatio f call-.
°f"� 7
installed. If a roof is installed without first obtaining an
Data Ayvl cam /
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPU If, alter making thio r trate of Exam -1 hould become
subject to me Workers Compensator, oraAelans oft a Lebon Code, List forthwith comply'
Applicant .understands and will comply with all no int
p y I�
won such proveors or this permlt ehalQbe deemed rooked.
source regulations. - '
I certify that l have read role application and state that me above Inlonnaton H collect. I agree
to comply with all city and county erdlnances end slate laws relating to building construction,and
All roof coverings to be class "C" or better.
hereby aumorlze representative, of this cty to enter upon the above-mentioned property for In.
specton purposes.
(We) agree to save, Indemnlfy end keep harmless me Cloy of Cupertino agaln6t IlabilNles,
<
,u marts, come and expenses which may In arty way accrue against said City In consequence
IRE APPqr4NT DATE
of the grenimg of this permit.
.SIG PIP: r -
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