R-6237 R- 6237 '
' PERMIT
APPLICATION FOR CITY of cuPERTINo NUMBER i
• INSPECTION DIVISION PERMITEXPIRATIOn
REROOF PERMIT- (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
_ WITHIN 1110 DAYS OF PERMIT ISSUANCE OR
1110 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS ,
! O / RESIDENTIAL COMMERCIAL OTHER
owNeR/$�� /J HAZARDOUS FIRE AREA
J /( YES ❑ 11 yes s understandlyisreq fluat a Class A
NAME �'f f!—�/LYLI l/�[iC.L:O Ciff d J root assemdy is required.
NO
Initial_ I.C.B.O.C
ADDRESS-,_SQ,"'-LJ_o` EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS /
CONTRACT '
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
IJ
CITYaZIP �- 6 EXISTING
PHON4G_5_Q'_--�J 3 X 63 73 BUILT-UP ROOF - ❑
CENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affrm that I em licensed under provision of Chapter 9(commencing with Seaton 'WORD SHAKES
7000)of DMson 3 of the Business and Professions Code,and my license U In lull force am
effect.
r/•1 q �-y WOOD SHINGLES ❑
License Clean Uc.Number T a I
QOTHER (SPECIFY) ❑
Date /—Cortvecmr
OWNER-BUILDER DECLARATION PROPOSED -
hereby affirm Bu that am exempt from the e: Any
License Lew for the vire.np realm.
(Sec.701.5 Business and Profor Tea Code: Any urs or county which requires a permitto
ue
construct,after ensu,Improve,d file asi or repeat any structure,prnrto Its Issuance,
rsuant also requites the BUILT UP ROOF
of the Ca for such permit License
ro Ills a Chaps statement that he U licensed pluralism to the provif ma
of Lha ss;and ore Lkerae Lew(Clatter 9 is ex a pt gg eWithref Sealed]000)of Dlvielhe 3 0l rhe' - -
exampea entl miatsbra SCode)edo or that he B exempt therefrom and the belle a the alleged ASPHALT SHINGLES ❑
a allpen.Airy uict onof SeNon found tryany applicant IwaperMteubjede me applicant to
e c0 penalty d net more then,or y employees
dollen with
wage C
❑Las nc!t ofMeproperty,or tsnxJW or ftewlthwages as(Sao.their edecompessatlon,will s- WOOD SHAKES ❑
the work,em the structure is rwt Interned or offered for cele(Sec.7044,Business entl Proles- r�
Bions Code:The Contractors License law does not apply to an owner of praperry w1ro builds or WOOD SHINGLES kill
Imprmae thereon,and who close such work hlmeeM or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.If,rnwevae me building or Improvement
Is sold within one year of completion,the owner-bulkier will have iia burden of provlrg fat he did OTHER(SPECIFY) fJ Lt.Cau
nol bUld or Improae for purpose of sale.).
❑I,as owner of the praperry,em ezdusMNeontrcellngwith fico d contractors to construct the
the project(sec.7044,Susmesa end aekxa ProfeCode:The Convectors Licenae Law does Trot PROVIDE I.C.B.O.REPORT NO.<EX—
appN to an owner of property who butlda or Impro ivo tenon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractors Ucense Law. PROVIDE MFGR.INSTALLATION SPECS.
I em exempt under Sec. ,B 6 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
- I hereby mV urner penalty of perjury afro of the following declaration:
lolWn: -
❑Ihaveandwillmaln 37a of the
abof Condor Medit-Insurefor of
we Compenmtlon, O� Building(
.petit is Is for by Section 3100 of me Lobar Code,for me performance of the walk brwhich rale p G / /•�
permit k leeuetl. I/`[ 9 ��76D of ,S QIP Seismic
have entl illor Me performance
Compensation Iwthich thisce,m required try Secfon Worker's / ��y
he Lobar Cada,for ai performance of ma work for which this Permit Is d by S.My Workers �/
-Compansell Inst`' carrier and Pollcy number are: Total
Cards A«'ale. Poky No.s71'99-1i2 S T AUTHORIZA ON DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C{] 99
(Tris secten.neeo net rn completed f the permit Is for ora humred done (St00)ar lase.)
I sonify that In the performance of the work for which Urs permit is IaeueE, shall not employ
emy permn In arty manner so as to become subject the W tare•Compensatkn Lswe of Can- All r s shall be inspected prior to any roofing material being
forma. - •ins ted. If.a roof is installed without first obtaining an
Date�/9 Apdkcertt i taction,I agree to remove all new materials for inspection.
NOTICE To-All It,afar mall this Cenmcat of Exemption,you ofil become A Ilcant understands and will comply with all non Dint
subject to me Workers'Compeneaten provisions of the Labor Code,you must lorihwlm corrtpry PP P Y P
_ with suet provkslons or No permit shatCoe doomed ro oked. Source regulations. '
I cera lty that I have read mro epplicaten and state that the all Informabon Is correct.l agree
to comply with ell city end county ordinances and state laws relin ng to building construction,and All roof coverin be clas "C"or better.
hereby all representetives of this city to enter upon the above-menticrted property for in. -
sprpos
pues
(We)
(We)agree too save,indemnity em keep hay way the e a of against
Cupertino Cl against Ilebllltlss, l
jutlpmento,mote and expenses which day In arty way eewe egelnet eeM Clty In eonmquertee
of tha granting of Me permit. SIGNATURE 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY - -