R-6074 PERMIT
APPLICATION FOR CITY OF CUPERTINO ' . NUMBER R" 6074
.
INSPECTION DIVISION PERMITExPIRAno
REROOF PERMIT (408)777-3228 PERIA IT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUIL1DING ADDRESS - 1 `x
OIj RESIDENTIAL/ COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
�a r - - YES 11yes—I understand that a Class A
NAME `�'\
Z>: \A 4 \ ��. E] roof assorl is required. .
NO ❑ Intial I.C.B.O.M
ADDRESS (n cow � O 1(�'-[- S\V 1 1 - EXISTING ROOF COVERING
PHONE / DL NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S TO BE RETAINED
'
NAME--CA
V 10./-' - \c—� ✓`��Q� TO BE REMOVED /
�O
ADDRESS �i '2 �+ !�7 / Q'� TYPE OF ROOF COVERING
CITY&P e� J L'i l ���. S. Vs�r-N r
EXISTING
PHONE 7�' "�S"oO BUILT-UP ROOF
LICENSE ❑
NUMBER D Q - ASPHALT SHINGLES'
LICENSED CONTRACTORS DECLARATION _
I hereby affirm that I am licensed under pr Wons of Chapter B(commending with Sedion WOOD SHAKES El
7000)of Division 3 of the Business and Professions Code,end my license Is In full force
ctend
effe . �
`
n INGLES ❑
Umnee Claes Lk.Number �� `�
Data Q 2� g Contreaor - y� ( ECIFl7
OWNER-BUILDER DECLARATION
hereby affirm thel I am exempt Iron the Contractor's License Lew for the fol rp re AU
(Sec.7031.5,Business and Professions Code: Any dry or county whi&requir permit to
tit
construct,alter,Improve,demolish,or repair any statement
prior to its lesuence,ale requlrae the BLI - ROOF ❑
applicant for etch permit icer to file a Chaps r 9(commencing
that g with
Section
Pursuant to rovlelons
of the ss andl Pre License Lew(Chapter 8(commending wIN Section 7000)of D' of the -
.
exemption.
ern viola
bbrs Code)or that he is exempt therefrom and Me besb f HINGLES ❑
exemption.Allyf not one Section 7031.5byolany epdicentfor a permit bub)pde the applicant to
e ciWl penalty of not more Nan flue hundred dotlete
❑I,as owner of Me prop",or my employees with wages as their ads compensation,will do WOOD SHAKES ❑
the work,and the structure Is rot Intended or offered for sale(Sec.7044,Business and Profes-
eons Code: The Contractors License Lew does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves Menson,end who does such work himself or through his own amp"", raWded that
Such Improvements are not intended or offered for Sale,If,however,the bulWing or Pmprovement
Is Sold within one year of comp'etkm,Me owner-bulder will he"be burden of proving Mel he did OTHER(SPECIFY)
not bum or Improve for Purpose of tele.).
0,as owner of the property,em exdushWy coneaclin wiM licensed contractors to construct
Me project(Sac.7044,Business end Professions Code:Tire Contractors UmnuuS Lew doe,not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of prop"who bulids orlmprpvee thereon,and who contracts for such projects r
with a contrectoge)licensed pursuant to the Contractors Ucenae Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. - ,B a.P.C.for No reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I Hereby affirm under penalty of perjury one of the following declaration: 7I]
he.and will maintain a Cenlllcete of Consent to self-Insure for Workers Compensation, - Building [ G
asp"roovided for by Section 3700 of the Labor Code,for Me performance of the work for which Min
t Issued.
?Vpar
have end MII maintain Workers Compensation Insurance,as required by Section 3700 of Seismicv
e bon Cade,for Me pedormence of Me wmk for which We permit'Is Issued.My Workers
Cowen"tl n Ineumnce caMerLlend P:y number are. 1 Total �L[
Carrier-f''T� ' '�K Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FRDM WORKERS'
COMPENSATION INSURANCE N.C.0
(This sedWn need not be completed If Me permit is for one hundred collate(5100)on lees.)
m
1 certify Mat In Me performance of the work for which this psrrrit le Issued.I shell not emW oy
any,person In any manner so m to become subject to the Workete'Compensation Iswt of GII All roofs Shall be inspectedprior to any roofing material being
fonts. installed. If a roof is installed without first obtaining an
Dale AyPticant inspection,I agree to remove all new materials for inspection.
NErkrsCosithis
Laa of ltrttcodays
subect IohWaiCompentuatlon pre ons of NLabor Cod you mat forthwith Applicant understands and will comply with all non point
with each provisions or this permit shall be deemed revoked. source regulations. -
I cer111y that l have read this application and state that the above Informetlon Is correct.l agree
to comply,with all dry and county oNlnenwes and stele Tawe relating to building construction,anc. •All r f CA� /Brirings}�y^�beclass°C"Or better.
hereby epue representatives of this dry,to enter upon the above mentlonetl property for Ira �/"�
hereby n purposes,r -
(We)agree to save,Indemnify arrd keep hermlete the City of Cupertino against liabilities,
N ments,costs end expenses which may In anyway accrue against saW City N carsequence SIGNATURE OF APPLICANT DATE
• ate granting of MIS permit. -
PRE-INSPECTION: PLYWOOD: IN-PROGRESS'
INSP. DATE INSP.—DATE INSP. fYJ DATE 7
TEAR OFF INSPECTION: BATTENS: FINAL
INS P. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY -