R-6273 PERMIT.
APPLICATION FOR CITY OF CUPERTINO NUMBER R�'- 6 2 7 3."
_ INSPECTION DIVISION P RMIT EXPI TION
REROOF PERMIT .(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
- WITHIN 180 DAYS OF PERMIT ISSUANCE OR
. 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS L
16 011 _/ 'il . .Djr— RESIDENTIAL—ZCOMMERCIAL OTHER
OWNER'S HAZARDOUS SHE❑ AREA
Q J� // YES . If yes-I understand that a Class A
NAME /' S 1 F7TN - NO roof essenti Is required.
- I_ ❑ Irl .I.C.B.O.N
ADDRESS ��d�q� pnB"w oS7�' D/ EXISTING ROOF COVERING
PHONE �� /O�� - " 'NUMBER OF EXISTING COVERINGS /
CONTRACTO(`R'S. y,` I
NAME— _Soy/ '"ryB��l✓J ' tap"�)q5 C6 TO BE REMOVED TO BE RETAINED
(�fy�
TYPE OF ROOF COVERING .
ADDRESS
CITY a ZIP17 .EXISTING -
PHONE 13 T ���SS� - BUILT-UP ROOF ❑
LICENSE
NUMBER 7o 5-0-5-C) ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
A hereby.Mirth that I am hoonced under provielons of Chapter g(commending with Sac om WOOD SHAKES -
7000)of Division 3 of the Business and Professlons Code,.and my Ilcense Is In full farce and
eHe
WOOD SHINGLES
(_[� ❑
Ucan m,Clese C 3� Llc.Number �O 570+ _
Dere ,�—Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors Llcense Law for the following reel PROPOSED - - - -
(Sec.7031.5,Business end Professions Code: Any city or county whldt requires a permtt o "
construct,after,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the B U I LT UP ROOF
applicant for such permit to file a signed statement that he Is Ilceroed ptrsuant to the provisions -
of the Contractors License Law(Chapter e( IN 101. of the
. ...moss and Professions o Coda)or that he e�empt fs and in Ia f a Iagad ASPHALT SHINGLES
Buftr ion.Any rofesions Cod) r031 that pplica 1$rb ermfte I nt to -
e civil penalty of rot more then flue hundred (E5 WOOD SHAKES [�(
❑I,as owner of the property,or myemp h wages as thdr eche comportb will do 4 '
the work,and the structure isnot Intend o ad r�gI ( c. rotes-
slons Cocke: The Contractor's License Law not an to ids or WOOD SHINGLES
improves thereon,and who dove each work elf o u h h e ed that ❑
such Improvements are not Intendetl«cHer or able.It however,the losing or ment
Is sold within one year of campletion,thaown - liderwIllhayethelcurderroliproyli gthu hedfd OTHER(SPECIFY) ❑ -
not build for Improve for purpose of sale.). D El 1,as ownerofthe property,am exclusly ygoMlagtlu- xn lP c truct
the project(Sec.7044,Business and ProlesOode.'9he'Ca snot PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who DUlltls or imprwas thereon,and who contracts for such projects -
with a contractor(c)licensed pursuant to the Conbsctore Ucarae Law. PROVIDE MFGR.INSTALLATION SPECS.
El em exempt under Sac. ,B 6 P.C.f«this reason
°"`ren oats - APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby.off ran under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to setiansure for Worker.Compensetbn, r/OO �- Bll hiding (J
as prodded for by Section 3700 of the Labor Cade,for the pedrm
ou nce of the work for which this 7(
pareissues. - Seismic P
1 hone and will maintain Workers Compeneatlon Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this I Is Issukers
ed.My Wor
-Compensation Insurance carder and Polley number are: Total
Carrler .5/*A P� �e NPi No. 1412:7 PERMIT AUTHORIZATION DATE
CERTIFICA1E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 1WftN.CQ1o __7
(This sxmikin neetl not be completed It Nthe permit Is for one hundred tldlare($100)or lase.) (' 0 7
I.Olfy the{in the performance of the work for which thle permit re issued, shell not emptoy
any person In any manner so as to become subject to the Workers'Campensakon Laws of CeII- All roofs shall be inspected prior to any roofing material being
fpr"a' - - installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for Inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will coon with all non point
subject to the Workers Compeneetion provisions of the Labor Cocke,you must forthwith comply pP comply P
with such provisions or this permit ehaftbe deemed revoked. , source regulations.
I certfty that I have read this application and state that the above Informathon Is correct I agree A
to campy wfth all city and county ordinances and costs laws relefing to building construction,and All roof coverings to be class`10*or better. .
hereby authorize representatives of this city to anter upon Ne above-mentioned property for In- J'
spe[We) purposes. //
(We)agree to eau°,expenses
and kay I harmless
way the City ai st sed
Ci against IIablltlies,
of the gran costs and expenses which they In any way eccme against said Clry in coraaquence TURE OF APPLIC DA
of the granting of this permit.
PRE-INSPECTION: PLYWOOiIN-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, -