R-6644 PERMIT R_
APPLICATION.FOR CITY of CUPERTINO NUMBER 6 6 4 4
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
/O n fol �j 5On / 1 1 RESIDENTIAL COMMERCIAL OTHER
OWNER'S _ HAZARDOUS
�]� YES ❑ "1-
yes- urldenbuid tllat a Class A
NAME Ll Q h �H4✓� - roof assembry is required.
• NO ❑ InMeJ I.C.B.O.tl
ADDRESS /01/6 _ EXISTING ROOF COVERING
PHONE - Q65% 0)[1W NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
NAME co,," _
TO BE REMOVED ./ TO BE RETAINED
NA '
ADDRESS33 Z / � 1Q'tyl.�� TYPE OF ROOF COVERING
CITY&ZIP "
EXISTING
PHONE 29�— 765" BUILT-UP ROOF - ❑
LICENSE
NUMBER �116SZ ASPHALT SHINGLES El
UCENSED CONTRACTORS DECLARATION -
I hereby affirm that I am licensed under provielons of Chapter B(commencing with Section VWOD SHAKES
7000)of Divi$Ion 3 of.the Business ars Professions Code,snot my license b In full force and -
affect. ^ 2 D INGLES ❑
License Claes Lc.Number `I
Date Cont actor OT R(SPECIFY) ❑
OI BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Conthl License Law for the bllvMng real
(Sec.7031.5,Business and Professions Code: Any dry or county which requires a permit to
mrmtruct,after,Improre,demolish.or repair any structure,prfor to its Issuance,elect requires the BUILT-UP ROOF ❑
applloent for such permit to file a signed statement that he Pa licensed pursuant to the provisions
of the Contrectofe L corse Law(Chapter g(commend ng with Section 7Wg)of Divlelon 3 of the
Business and Professfons Coda)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exempbon.Any vfolatlon of Section 7031.5 by any applicant for a penult subjects Me applicant to
a dull penalty of not more than five hundred dollere($500).):
❑I,as owner of the property,or my emplayess with wages as Noir ode comwnswon.will do WOOD SHAKES ❑
Me work,and the strvdure Is not trial or offered for sale(Sec.7044,Business and Profes-
sionsCode:The Connector's"nee Law does not appy to an owner of prop"who bullet or WOOD SHINGLES ❑
Improves thereon,ark who does such work himself or trough his own ampoyyees,provided that
such Improverrrents we net Intended or offered for sale.If,howwr,the building or Inn r meat
is sold within one year of completion.me owner-bulider will have the burden of proving met he did OTHER(SPECIFY) ❑
W Wild or Improve for purpose of vele.).
El 1,as owner of the property,am exclusively contrechwith licensed convenors to co mutt
Me project(Sec.7044,Business matProfessions Cade:The Contractors Ucenes Lew plows not PROVIDE I.C.B.O.REPORT NO.
appy to an owner of property who bulks or unprovws thereon,and who contracts for such projects
with a contraction(s)licensed pursuant to oro CmMuctors Ucsnse Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECIARAnON
I hereby affirm urraw penalty of perjury ane of the fallowing declaration.
❑I haze and will maintain a Certnlcete of Consent to self-Insure for Workers Compenswon, /-•� Building
as proxided fon by Section 3700 of the Labor Code,for me performance of the work for which this L/v/ [/rD _ g /
permit Issued. 1/ r -(
I have aM will maintain Workers Cornpensstfon insurance,as required by Sectors 3700 of Seismic
the bon Cade,for the performance of the work for which this permit La Lssuad,My Worker$
Compeneetbn Ineurence farri�e.r end/F/iley number are: ']Q Total
Carrier 5 [ 1 Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' .
COMPENSATION INSURANCE N.C{]
(This section need net be completed If the permit Ie for one hundred dollen($100)or lees.) m L 7
cantly that In itis Performance of the work for which this permit b I$euetl,I shelf retemp Iq `
any wmn In ariymanner so ss to bemme subject to the Worker'Compenmtl"Lew$off 11- All roofs shall be inspected prior to any roofing material being
fon"a. 2 �J/ / /_ installed. If a roof is installed without first obtaining an
Doe 7 `—� Apalicant /`�" `^^^-^� Inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: II,after making this Certlncate of Exemption,you all become A llcant understands and will with all point
subject to Uro Workers'Compensation provisions of the Labor Con,you must forthwith comply PP comply P y non
with such provisions or this permit shell be named revoked. Source regulations.
I ceNty that I have read MIS appllcatlon and lists Met the above information Is conect.I agree
to comply with all city and county ordinances and$rate leve relodng to building construction,ens All roof coverings to be Class"C"Or better.
hereby auModze reprssentelMe of UJe city to anter upon the above-mentimetl property for In- 2-
specti(We) agree toe.
(We)agree to$eve,perl Indemnify w end keep harmless,was the City ai st mid r1 against IIabllltlee,
Judgments,Me gran costo tris expenses which they fo airy way accrue against seltl Clry In casequerxxr
of he granting of ime pe mi SIGNATURE OF APPLICANT DATE
PRE-INSPECTION:. PLYWOOD: IN-PROGRESS:
INSP DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATES INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY .