R-6398L
E
PERMIT R_ 6398
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION - PERMIT c Iron N
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
•
WITHIN 1130 DAYS OF PERMIT ISSUANCE OR
1W DAYS FROM LAST CALLED INSPECnON.
BUILDING ADDRESS
^�y-
7µS4 V' F -w _'>r'
RESIDENTIALJ� COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
�1✓I' j-
r' Sd iii an I
YES E] If }res — I understand that aClass A
is
NAME—r 1
-
,rod assembly required.
NO Initial - I.C.B.O. F
EXISTING ROOF COVERING
ADDRESS`S
p �y
PHONE 2 S S— 8 1 1 3
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S -
JoSJ
TO BE REMOVED TO BE RETAINED lJ
NAME
ADDRESS 29q •��.s•�.t.t 5�J 9SII
TYPE OF ROOF COVERING '
CITY & ZIP
EXISTINGS1-,
(Ltod) 21 1— 61 �' I
PHONE
❑
BUILT-UP ROOFLACENSE
NUMBER r1_31 99o
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION -
I hereby anlrm that I em licensed under proWelom of Chapter B (commencing with Section
WOOD SHAKES
7000) d Division 3 of the Business and Professions Code, and my license is In full force and
ones.
��jp
OSCI 7399p0�(
WOOD SHINGLES
License Close Lk. Number
..
Dote Tll9Ll Contractor � J ND11 r/�. �c •
OTHER (SPECIFY)'. :0 �
OWNER-theBUILDERDErsLiceION
PROPOSED
hereby that am exempt from ins cry Lkenee Lew for the following reason.
-
(Sec. 7031.5, , Bu Code: Any
Any dry or county wnkh requlros a perms to -
entl Prohdish,
r, mwose
alter, Improve, or re itan
any Structure, poor to fie Issuance, also quires the
BUILT-UP ROOF
to his a signed statement pursuant to the pro
applicant to the
applicant for such permit to file a egad statement Inst
of the mre License Lew (Chapter B g with cro 7000) of DMsbn 3 of the
of the
Business end Professions 15 o,mendrg refrom and
ss and! Cede) or that he la axampt therefrom end the Dade for she ellegetl
ASPHALT $LIFY)
f
exarrrptlon. Any violation of Section 7031.5 by any applicant for a permn subjam the applkenl to
-a cvIl penalty, of not mora than five hundred dollars (S5Do).):
-WOOD SHA
❑ I, as owner of the property, or my employees with wages a f their sob comperuetkn, will do
Me work, and the Structure Is not Intended or offered for eels (Sec. 7044, Business and Prefers -
Sleds Code: The Contractors Ucerse Lew Baas not apply to at owner of properly who builds or
Improves thereon, does himself Ms
WOOD SHIEB g 1_q9
D
entl who Such work or through own employees, pro that
such Improvements we rot Intended or offered kr sale. If, however, gra Watling or Improvement
-
Ieeoldwnhinoneyearofcompletlon, the owner -builder will have the burden of proving that he did
OTHER ($Pnot
Wild or Irtprove for purpose of sale.).
01, as owner of the property, am exclusively contrectlrq with licensed contractors to construct
Business,
,I A
ROVIDE I.
the fact (Sac. 7044, and Professions Cade: The Contractors License Law does not
J�J
apptylo an owner of property who builds or Improves thereon, and who contracts for such projects
1
with a contredods) licensed pursuant to the Contredor's License law.
PROVIDE MFGR. INSTALLATION SPECS.
F7 am exempt under Sao ,B a P. C. for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following daleretkn:
❑ I wive and will maintain a Cemnkato of Consent to sa f -Insure for Workers Compensation,00
Building/ 7
as pro,ded for by Section 3700 of the Labor Code, for the performance of the work far which this
paI
Workers Compeneotlon Insurance, urs by Se 3700
' 99��
a -q -9q ,/ �� Seismic �p
e didwill maintain as rec of
the Labor Cade, for ire performance of ire work for whldr this Permit Is Issued. My Workers
7
Compeneadon Insurance carrier and Policy number are:
Total/`�
Carder �`� �hs- alryNo.IAICI'62W75'7
PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 100) o
(This eectlon road rot W completed n the permit Is for one hundred ddlare ($100) or lase.) �
q
I comity it In the performance of the work for which this pernds Is Issued, I Shell not em loy
any person In any manner a as to become Sublet to the Workers' Compensation Laws of �b
(/
All roofs shall be inspected prlor to any roofing material being
fornix.
installed. If a roof is installed without first obtalning an
Date Applloant
inspection, I agree to remove all new materials for inspection.
NOTICETOAPPLICANT: If, after makingthisof of oxemyokmets f-th�ithcoao�
auojed to the APPLIICCampe, after rovWons of the care Cada,
-Applicant understands and will comply with all non point
with such provision or til permit shell be doomed revoked.
Source regulations.
I tardy that I have read this application and state that the above Inknmaffon is carted. I agree
°
to comply wither dry erg county ordinances and were laws reladng to puddling construction, and
All roof coverings to be class or better.
hereby authorize repreeanumves of this City to enter upon the above-mentioned property for In.
'
epecdon purposes.
- agree W save, Indemnity and keep harmfaae the City of Cupertino against Ileellltles,
•oldtherenticoso
-
g(We)
dads �xpeneee which may In em wev accrue egelrut sem City In coneequenw
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