R-6426 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R" 6426'
INSPECTION DIVISION - PERMIT- cPIRATION
REROOF PERMITL (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1130 DAYS OF PERMIT ISSUANCE OR
1130 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
toa1� Co\d likuvbar fb[n�L
C.>lcrh A C\S-OVLA RESIDENTIAL COMMERCIAL OTHER
OWNER'S- - HAZARDOUS FIRE AREA
' YES ❑ II yes—I understand that a Clear A
NAME 1 5bAQ n - root assembly is required.
NO ❑< Initial I.C.B.O.0
ADDRESS EXISTING ROOF COVERING
PHONE
CACI V re ( NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
-
NAME .+ Co e�1YG-4C1 .•x.. \hL , TO BE REMOVED TO BE RETAINED
ADDRESS - - TYPE OF ROOF COVERING
CITY a ZIP Shy&g& 1�— EXISTING
PHONE C-% t - aooy BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINKELICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under Prrovisions of Chapter B(cmvnencing with Section WOOD SHAKE7000)of DMelcrn 3 of the Business entl Prolesslorna Cade,entl my Ilcenee le In lull force anti
effect. R'CSFA 5aS7�� WOOD SHINGL ❑
Llcrose Claes Dc:Number
Date S-�'q`'1 Connector •�'w-� Ce..cNr+... OTHER(SPECIFY)
OWNER.BUILDER DECLARATION PROPOSED
I hereby still that I em exemctors pt from the ContraLicense Law for the following reason.
(Sec.7031.5.Business and Professions Code: Any city w county which requires a permit to
corutrud,after,Improve,domotlsh,or repair any structure,prlor to Its Issuance also requires Me BUILT UPf F
applicant for auUl permit to file a signed statement that he Is Iiceneed pursuant to the provisions
�> of Me Contractors-fool a LewChapter 8(commencing with Sector,7000)of Division 3 of the
Business and Profedskos Codes or that he Is exempt therefrom and the beat for the alleged ASPHALI SINGLES
exempilon.Any vlolaton of Section 7031.5 by any appllcent for a permit eubjma tiro applicant to
e civil penalty of rot more than five hu lred dollars(3500).):, " C
C]1,as owner of the property,or my employees with wagesas their ads conryreneadon,will do WOODS KEW U 1999
5
the work,and the structure Is not Intanced or offered for sale(Sec.7044,Business and Prates- I -
slope Code:The Contractors License Law does not appy to an owner of property who bulldn or WOOD S�"IINGLES
Improves thereon,ark who does such work himself or through hie own employees,provlded that
such Improvements are not Intdnead w offered for said.II,however,Me building w improvement
Is sold wltNn one year of completion,the owner-builder will have the burden of proving that he d'd OTHER(S.
not Wild w Improve Iw purpose of vele.).
❑I,as owner of the property,am exclusively contrectng with licensed contractors to construct
the pro)mt(Sec.7044,Business and Professions Code:The Contractors Ucenes Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an ownar of probe rty who bulbs orlmproves therein,and who contracts for such projects
with a ccnrmctor(e)licensed pursuant to the Contractors Ucerroe law. PROVIDE MFGR.INSTALLATION SPECS,
❑1 sm exempt under Sac. ,B&P.C.for this reason _
Owner -
WORKER'S COMPENSATION DECUBATIOT10 N
APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under peristy of poll one of the fallowing declaredon:
❑I heed eM will melnr37 a of the L tB of ode,for to eperorma for Workers Ca rf:hl hon, ../ QO
as 71 he dl Sl ction men3700 of the Lab or Code,for the performance for of Wireworkbrw-abon, Building �L
permit elf. $eISR11C
and will moll Worker's Campensaaon Insurance,as required by Section 3700 of
the Leber Cade,for Me performance of the work for.whldh this permit Is Issued.My Workers
Compensatlun Insurance center arta Policy number are: VN( _' Total
Carder sctc-Y"- •x ropeyN..,_1�_9 1 0WQ"qS. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This matron need not be completed t Me permit Is for one hundred dollars($1 N)or lees.)
I cardty that In the performance of the work for which thio permit Is Issued,I shall not employ
any person In any manner so as to become subject to th`e Workers'Compensation Laws of Cani g
- All roofs shall be inspected prior to any roofing material be
fomla. installed. If a roof is installed without first obtaining an
Date 3"S -4"L Applicant •� ` inspection,I agree to remove all new materials for inspection.
NOrICE TO APPLICANT: If,after making MIs Certificate of Exemption,you should becorto Applicant understands and will comply with all non dint
subject to the Workers'Compensation provisions of the Labor Code,you must lorthwlM comply pP P Y p
with such provisions w thFe permit shell be deemed revoked. source regulations.
I cel that I have read thio appllcadon and state that the above Information in cwract.I agree
to comply with all city end county ordinances and state laws relating to building wnstructbn,and All roof coverings to be class"C"or better. -
hereby euthorlsa representatives of thio city to enter upon the abrrve mentioned property for In.
spaction purposes. x L q
(We)agree to save,Indemnity and keep harmless the City of Cupertino against Ilebllitles, /'
.jurlamenb,costs and expenses which may In any way accrue aglnet asaid City in consequence SIGNATURE OF APPLICANT DATE
of t s granfing of this permit. -
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP.' —, DATE INSP. DATE INSP.-DATE
TEAR OFF INSPECTION: BATTENS: - FINAL:.
INSR - DATE INSP, DATE INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
' OFFICE COPY