R-6592•
4k
OFFICE COPY
PERMrr R_ 6 5 9 2
APPLICATION FOR CITY OF CUPERTINO NUMBER
. INSPECTION DIVISION PERMIT EXPIRATION
REROOF. PERMIT (408) 777•3228 '. _' PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
' - 100 DAYS FROM LAST CALLED INSPECTION..
BUILDING ADDRESS
lam C-'
►JL Ate
RESIDENTIAL— COMMERCIAL OTHER
OWNER'S
- HAZARDOUS FIRE AREA
A (yy`
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YES 0 If yes _ I uMy Class A
NAME V , `r / /�
is required,
roof essernbly a requredt
NO Initial LC.B.O. >t
///
-EXISTING ROOF COVERING
ADDRESS— a ��. (,�2
PHONE L.FO 7 —4-7 o
NUMBER OF EXISTING COVERINGS
-
TO BE REMOVED TO BE RETAINED
CONTRACTOR'S
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EA
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NAME YV IV `-'1 CI
l�L
ADDRESS" / f p pA f �' T C'' coot
U 1 �J lA
TYPE OF ROOF COVERING
CITU, C�VV l ..-
EXISTING
'ZIP
5-10 I
PHONE
BUILT-UP RO 1
/��
6 8( L
I
NULICMBER
ASPHALT S LESN 15
JU 1f1P D
WOOD SH S J
LICENSED CONTRACTORS DECLARATION
I hereby Met I Ilc¢neoa Chapter 0 Section
affirm em under prWsins of (commencing with
7000) of DNlelon 3 of the Buslness and Profesalons Code, and my license Is In lull force and
-
effe
(j 69 I
��
WOOD SHI S ❑
License Claes U..Number
I
OTHER (SPECIFY)
Data Contractor
10✓DOWNER-BUILDER DECLARATION
,
Z/3/
h reby affirm I at I am exempt from Me Convactor'e Ucanso Lew for Me following reason.
7031.5, Business Professions Cone: Any to
PROPOSED '
PLAN '
(Sec. and city or county which requlrea a permit
wnetruct,eller,Improve, eemolish,or repair any structure, prior to its Issuance, also requires Mi,
applicant for such permit to fee a signed statement Net he b licensed pursuant to Ne provision
Fp p�
B� Qt]rfY16 ROVgL REQU�p
'I tJ`{-`('NAL OCCUPANCY
of the Contractors Ueense Lew (Chapter g (eommendng with section 7000) of (NyIson 3 of me
Business and Profeeabne Cade) or Mel he Is exempt therefrom end the barb for the ellege0N�T
HINGLES
exemption. Any, vfobtion of Section 7031.5 by any applicant for a p rl sublecte the applicant to
❑
VV BY:
a dull penally of not more than INS hundred dollars ($5001.):
I, the
WOOD SHAKES ❑
❑ an owner of property, or my employees with wages as their sole campeneatlon, cal
the work, and the Structure is not Intended or offered for vale (Sec. ]044, Buslnaea entl Pr a
alone Cade: The Conirectore Dcenee Lew does not epPN to an owner of property who foul r
Improves doss himself his
�c.l{nyA��y������
thereon, and who such work or through own employees, pr
Such Improvements are not Intended or offered for seta. If, InKmeo ea Me bulltling or ip nt
Is Wdwrthinoneye letion,theowmer-WMerwiUha Mathenln
-
ofc eWu nofproWng
THER(SPECIFY)
not build «Improve for purpose of eats.).
Ell, as owner of the property, am exclushely contracting with Pceneed contractors to construct
the project (Sec. 7044, Business and Profession. Code: The Convectors License Law does not
IDE I.C.B.O. REPORT NO.
apply to an owner of property wire buffos or Improves Maroon, ane who contracts for such projects
win a cammaogel ticeneed pursuant to the Contractors License Law.
PROVIDE MFGR. INSTALLATION SPECS.
❑ I am exempt under Sec. ,B & P. C. for this reason
Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
-
WORKER'S COMPENSATION DECLARATION
-
I hereby affirm under penalty ofperjury one of the following decleradan:
El I hays entl will maintain a CertiHcata of Consent to aeff-Insure for Workers Compensation,
IS, prmid ed f« by Section 3700 of the Labor Code, for Me performance of the work f« which Wa
is Issuer. -
Building/�—
permit
/
.Seismic
E]I have entl will maintain Worker. Compensation Insurance, ne required by Section 3700 of
Me Labor Code, for Mei performance of the work for which this permit Is issued, My Workers
Total
Compensation Insurance carrier end Policy number are:
-��Q /y
PERMIT AUTHORIZATION
DATE
Center - wlloyNo.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE IN)o
(This eac1bn neetl Trot be mmpbtetl H Me PormN le for one huntlren tidier (5100) or leve.)
n
1 cartlty that In Ma performance of the work for carders MIS pemJt Is Issued, shall not emp oy
any peel M any manner ao tie to became Subset to Uro Workers' Compensation Laws of Call-
Al roofs shall be inspected prior to any roofing material being
lomb,
installed. If a roof is installed without first obtaining an
Date Applcant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, after making MIS Certlticate of Exemption, you should become
eubleet to Me Warkers' Compensation provblons of no Labor Cade, you must fodhwlM comply
Applicant understands and will cont Wlttl all non Int
PP Ply' PO
with such proviskxw or MIS permit shell be deemed revoked.
source regulations. -
I cerMy Mat I have read this application end state Met to some Information is correct. I agree
to comply with all city and county ordinances and state laws relating to building conatmctlon, and
All roof Coverings to be clas46 or better.
hereby euthorbo repreeentatites of MIS city to enter upon the above-mentioned property for In-
apedfonagrfeto
(We) agree to save, keep harmlessway the City of CupenllCleg alnet IIa�IIHbe,
f�
pensIndemnify which
judgments, ants and expenses carders may In any accrue against saki Clry In catuequeKe
SI OF APPLICANT DAT
d Me iFanting of MIS permit.
PRE -INSPECTION;
PLYWOOD: x
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