R-6430 ,r rr PERMIT R•
APPLICATION FOR CITY of CUPERTINO NUMBER 6 4 3
INSPECTION DIVISION � PERMITEXPIRATION
REROOFPERMIT (408)777-3228PERMIT EXPIRES IF WORK IS NOT STARTED
- WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 LAYS FROM LAST CALLED INSPECTION.
0 BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S - - .HAZARDOUS FIRE AREA
/A�////����� � �/ /yJ /^,�e� YES ❑. If yes—I understand that a Class
NAME—_"%/7's'YXlh -%li '^e^5"X1 root assembly is required.
NO. ❑ Initial I.C.B.O.It
ADDREss--�0%h 3SQ"r` EXISTING ROOF COVERING
/!
PHONE D D NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
Q� TO BE REMOVED TO BE RETAINED
NAME G45 G
ADDRESSTYPE OF ROOF COVERING
CITY&ZIP /d 0 Z
EXISTING
'PHONE Q Z — BUILT-UP ROOF ❑
LICENSE
NUMBER - ASPHALT SHINGLES ElLICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provbione of Chapter 9(commencing with Sakdon WOOD SHAKES
7000)of DMsbn 3 of the Business and Professors Code,and my license b In full force and '
arced. WOOD SHINGLE ❑
Ucanee Class -_ Lk.Number Al q
Date 9'✓r0 —OD contractor G �00/L/ I�ih OTHER(SPECIFY ❑
OWNER-BUIMER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for Me Idlowing reason.
(Sec.7031.5,Business and Profm1one Code: Any city or countyr
which requires a permit to
corvtrucL
he r,Improve,demolish,or repair any structure,Prior to Its Issuance,also requires the BUILT-UP ROOF
epPllcent for such permit to file a signed t tatemem Chet he Ie licensed pursuant to the provisions /(1 of the Contractors License Law(Chapter 9 commend wllh Sectl0 DMelon 3 of Me v
Business and Probations code)or 9t9t A re r e for the elapseASPHALT SHINGLES
exemption.Any%robdon of SecBon byanytfor a emb su the applicant to
e chil Penalty of not more than ffye rlpq their
j
❑I,ee owner of Me property,or kryeas wah wage.as olr sola han,wlu do WOOD SHAKES
the work,entl a structure b not In or offered Iqr sale(Sec.7044, u and Prolong-
810"
rolo g-
810"Ccde:TheContradoesLlcen Ley dpe9 rxl0ep0 erry61d16r1o1 who bunds or WOOD SHINGLES ❑
Improves therean,argwho does dhTTmm�LMMddrr ra INiaa77�xvil��m Pprwldetl Met
such Improxemente era rat Int offered for sale.II,however,Ma W or bnprorement
Is sod within we year of completion owner.. or win have the Write gMet he did OTHER(SPECIFY) X
not build or Improve kx purpose of I fle.). ,
I,as owner of the property,am x y contracting with licensed a tors to construct
the projec re taw does not PROVIDE I.C.B.O.REPORT NO. �!3
appy to an owner of property who bulls or Inproyes thereon,and who contracts for such projects
with a contractor(.)licensed pursuant to the Contractor.Llcenee Lew. PROVIDE MFGR. INSTALLATION SPECS.
1 am exempt under Sec. ,B 8 P.C.for this reason
Omer Date
WORKERS COMPENSATION DECLARATION- APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury oro of the following declaration. - O 7
❑I have and will maintain a Certlflcete of Consent to ee9-Insure for Workers Compensabon, BUlldln
as provided for by Section 37W of the labor Code,for Me Performance of Me work for which MIs '
per It Ia issued. /� �/L�,y /G r�
I have entl will maintain Workers Compensation Insurance,as required by Section 3700 of 1.� i 9 // c/ 1D SBIS1m,IC
I Code,for Me performance of Me work for which this permit Is issued.My Workers TOtal'2 O
Compensation Insurance carder and Polky number are:
•CarrierL�74 �+/ rollcyNo. 0 ' PERMIT AUTHORIZATION DATE
CERTIRCA OF EX,EMPT10N FROM WORKE
COMPENSATION INSURANCE N.CQ
(This section need not be completed If the Permit is for one hundred dollars($100)or less.)
1 cartity Met In Me performance of me work for which his permit Is blued,I Mall not employ
any person N anY manner su u to become eMjeel to tits Workers'CampervaWn d ,Allrootsshall be inspected prior to any roofing material being
99 k""a. 4 —, ` installed. If a roof Is installed without first obtaining an
Data Z�`! Applicant aA inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT:'if,after meting thle Certificate of Exem en,you should becgrne Applicant understands and will comply with all non int
subject to the Workers'Corryaneatbn pmNskme of me Labor Cnde, ou mi s forthwith compty pp p y PO
with such provisions or his Permit Mall be deemed revoked. Source regulations.
I cortify Mat I have read this apoladon and state met the above Information Is coned.I agree
to comply with all city and count'ordnances ane amts laws relatblg to Wilding conslmctfon,and .All roof Ings to be cla or better.
hereby authorize represantadves of this dry to enter upon the eboya-mentioned property for In.
spedlon purposes.
(We)agree to save.Indemnity and keep harmless Me City of Cupertino against IlabilNes, Z
judgments,coats and"Panne which may l arty way accrue against sad City In consequence
of me granting of this permit IGNATURE 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 -