R-6404 PERII R_ 6404 .
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT �-7 (408) 7n-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
,_ Gp_ —L' WITHIN 180 DAYS OF PERMIT ISSUANCE OR
O 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS `�}�� 7L AveA 11 LI}•
101514 f/r/�I/�' 1�V• `�V I 1 RESIDENTIAL COMMERCIAL OTHER
OWNER'S - - I HAZARDOUS FIRE AREA -
M1 YES H yes—I understand that a Class A
NAME 1 �JI M" Ai D A roof assembly is required.
NO Initial ' I.C.B.O.If
EXISTING ROOF COVERING
ADDRESS �J
LA—
CON
X �I✓� ry NUMBER OF EXISTING COVERINGS _ /r
PHONE U— /v 7
CONTRACTOR'S
`.� �j b�y`N�j TO BE REMOVED TO BE RETAINED
NAME r/ Tl 4 r A,m` r ry
ADDRESS IUB y )A Y� � (yl
fYPE OF ROOF COVERING
CITY BZIP—
EXISTING
PHONE - "'�— BUILT-UP ROOFLICENSE
❑
NUMBER l - ASPHALT SHINGLES .
UCENSED CONTRACTORS DECLARATION ,
I hereby affirm met I em licensed unser provlslons of Chapter a(commencing with.Settlor WOOD SHAKES '❑
7000)of DNIMon 3 of the Business entl Professions Code,and my license a In full bice and
effect.
r 2? �r,9 WOOD SHINGLES
Llconee CGleee Llc.Number '2�! 1' '
Data I—% —ny ContractorRWI OTHER(SPECIFY) AIVI;,
OWNER-BUILDER DECLARATIONPROPOSEDI hereby ,Bu that I em exempt Irom the Contractors or coue Lew ror the uires a g reason.(Sec.uct, b, , improae entl Professions Cade: Arty dty or oouny witch requires a permit to
carntrucL ensu,Improve,demola signed
or repeat my ntructuro,prix to ss Issuance,uant also reproves me BUILT-UP ROOF ❑
applIcardo Co for such permit to Ills a signed statement that he le licensedalio pursuant to the pro of the El
the Business an dors Ucense Lew(Chapter h is ex encing with Section to b of for the 3 0l the
exampss end Pro lotion f Code)of that he U exempt ant for
ark me beets for me sant to ASPHA SHINGLES
exemption.Any violationof SectionfW 7031r byartyapplicantfora permit aubjecte the applicant to
e dull penalty of not more then INe huntlred tldlers(Ssoo)J:
❑I,ea owner of Ne property,or my employees with wages as their sole compensation,will do WOOD KES Q Q
the work,end the structure Is not Intended or offered for Bele(Sec.70N,Business and Proles.
alcm Code: The Contractors Ucense Law does not appy to an owner of property who Wilda or
Improves thereon,and who does such work himself or through his own employees,provided that W00 INGLES
-such Imprommente are not Intended or offered for sob.It,however,me building or Improvement ILIA
is and wlmin one year of completion,the owner-builder will ham the Wncen of proving that he do 0TH (SPECiPY)? J
9 999
not Wild or Improve for purpose of sale.).
❑1,as owner of the property,em exclueNdy cormacing with licensed cantmctors to construct
me prcled(Sec.7044,Stamm and Profession.Code:The Contractors License Lew does not PRO i5E I.C.B.O.REPORT N
appy to an owner of property who bulbs orimproms maroon,and whD contracts for such projects '
,um a contractor(s)licensed Wrsuant to the gopfratews License Law.
❑I em exampt under Sec. . -^ ,B a P.C.kx thio reason PROVIDE TION PECS.
Owner '11 AIRO APPLICATION DATE VALUATION PERMIT FEE.
' WORKER'S NSATX)N DECLARATION
I hereby affirm under psnaly of perjury one of the folbwing dederetlon: - -
❑1 hem and will maintain a Cendkate of Consent to self-Insure or Workers Compensation, Building
as provitletl for by Section 37OO of the Labor Code,forme pedorman�of ihe�for which rola
�p m Issued. Seismic
I hove snd will maintain Workers nsation Insurance,as r uored Section 3700 of
r Code,lot the performance of me work for which rue permit Is Issued.My Workers
eneeti Insumrwa er entl PoILy number ere: f�T/� Total
Carrier - Poll"q`/ 'l- 1 6 1 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C{]
(This section need not be completed 1 me permit b for am hundred ddlZI ($
100) r lees.) l —I
I cerlity mal In the performance of the work for which this permit Is issued,I shall t employ
any person In any man urr co as to become subject to the Worxere'ComperaabonLa of coo- II roofs shall be ins prior to any roofing material being
1oril° Installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT. It,after m e "rotate of Exemption,you should became Applicant understands and will comply with all non point
subject to the Workers'Campensetio r of ma Labor Cada,you must brihwith comply
with such provisions or this permit ed revoked. source regulations.
I sanity that have reed rob epplkat aM amts met the above Information is correct.I agree
to comply with all city and county ordinances and state lave relating to building conetru All roof coverings to be class"C"or better,
hereby authorize representatives of this city to enter upon me above-mentioned pro
spoctlon purposes. -
we)agree to.eve,Indemnity and keep harmless the Clry of Cupertino agal t liabilities,
jud mento,vests and expenses which may in any way,accrue against said Cry,,, neaquence
of �e graming of this permit. CaNATURE APPLICANT ATE
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY