R-6405 PERMrr
APPLICATION FOR clTv OF CUPERTINO
NUMBER " 6405
e. INSPECTION DIVISION PERM IT EXPIRATION
-REROOF PERMIT - (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
r WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION. -
• BUILDING ADDRESS
LOIlrajISoYJ 6 ^ RESIDENTIAL COMMERCIAL—'OTHER
OWNER'S /' HAZARDOUS FIRE AREA
/T%r�.{�._r,�/ �A,p(I., ,C�, YES ❑. If yes-I understand that a Class A
NAME li�G�n`.�ti J11N,lll/,l . . root ease"*is required.
- 1 NO Initial LC.B.O.
ADDRESS EXISTING ROOF COVERING
PHONE {U U NUMBER OF EXISTING COVERINGS
CONTl
RACTOR'S},
`IL .TO BE REMOVED TO BE RETAINED
NAME fUr N
ADDRESSTYPE OF ROOF COVERING
CITY B ZIP AlK N /1L.t tip TL-. IA)5
PHONE 40k- I2�-99l
9 I Iq�J BUILT-UP ROOF ❑
LICENSE
NUMBER 2 l ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECIARATION ��tcc�irrr
I hereby-allirm that'I am licensed under provlaws of Chapter 0(commendrg with Section WOOD SHAKES
7000)of Division 3 of the Business and Profealalons Cade,and my Iioenae Is In full force and
erred..^ pLI ^ 2WOOD SHINGLES )
Ucm ae C �, El
be.Num ^r l
Da 1-30 09nt �• �UDFIt� OTHER(SPECIFY) ❑
OWNER-BUILD N PROPOSED
I hereby affirm that I am exempt from the.Convectors Lkanse law for the following reason. -
(Sec.7031.5,Business art Professional Code: Any city or county which requires a permit to
construct,after,Improve,camollah,or repair any structure,prior to its Issuance,also requires the BUILT-UP ROOF ❑
appllcent for such permit to file a signed statement that he Is Ilcenaed pursuant to Ne provlslons
of the Contractors Ucenco law(Chapter 0(commencing with Section 7000)d Division 3 of rhe .
Businesal and Professions Code)or that he Is exempt therefrom and the basis for the staged! ASPHALT SHINGLES
exemption.Any vblatlon of Section 7031.5 by any applicant for a permit subjects the applicant to
a dvil penally of not more than five hundred dollars($500).):
❑I,as owner of the property,or my emplyeas with wages as thdr ode compensellon,will do OD SHAKES ❑
Me work,and the structure Is not Intended or offered for sale(Sec.7040,Buatneas and Pn.-
sionsCode:The Contractors UcenseLa.does not apply toanownerofpreperrywhobuild,or FPROVID-E
Gl�S ❑Improves thereon,antl who does such work himself or through hie own empkryees,provided whet �uJsuch Improvements ere not Intended or offered far sale.If,however,the bulldlrg or Improvement
la sold within one year of completion,the owner-bulker will hese Ne burcen of proving that he did ECIFY)not bulk or Improve ler pure ,e of sale.). 'L(�(1(1,m owner of the property,em exclueWdy connecting with Ikensed contractors to ccrta ucYme project(Sec.7044,Buelneea antl Professions Code:The Cono-anors Ucense Law does not. C.B.Oi,R NO.
apply to an owner of property who Wide or Improves thereon,and who contracts for such projects
with a conhactor(e)licensed pursuant to the Contradars Licence law.
❑1 am exanpt under Sec. ,B 8 P.C.for Ma reason By PROVIDE MFGR.IN CATION SPECS.
O*m Dole APPLICATION DATE UATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the for oWng dedaratlen:, -
El1 �+'�_I hese and will maintain a Certificate of Consent to alert-insure for Workers Compensation, Building ' r
as provked for by Section 3700 of the Labor Cede,for the performance of Ute work ler which thio �s p r,
permit is Issued. ^I l llplq 1 O 'O Y w $BISSeismicL ` O
XI have and will melnieln Workers Compensation Iheurenco,as required by Section 3700 0l / I 1 0
.Mb Lobar Cade,ler the performance of the work for whichthis permit Is issued.My Worker's' I
Compensation
Insurance carder and Polley number ars: - Total ` IC)
Carrier '!LL`s 7.4t•7� Po1kyNo— 511-1ob�6 PERMIT AUTHORIZATION. DATE
CERTI CITE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.E)
cwt (�4
(Thus section more t be cor plated If the permit Is kr one hundred dollen($100)or lee,.) g `
I corlity that In the performance of the work ler which this permit Is Issued.I shall not employ
any paean In any manner alo as to become subject to the Workers'Compensellon Leve of Call- All rooTMall be inspected prior to any roofing material being
fo Dia. installed. If a roof Is installed without first obtaining an
Date Aupncpayt a r inspection,I agree to remove all new materials for Inspection.
NOTICE TO APPLICANT: If,after me edtlbate of Exemption,you should become Applicant understands and will comply with all non-point
subject to the Workers'Com ration rw1G of the Labor Code,you must brthwMth comply PP P Y
with mrdr provlsbns or this permit shelQbe deamed revoked. source regulations.
I certNy that l hese read this application and state that the all mistrusted is err
tocompfy with a cityarrocountyordlnenceeend state laws retstingtobulldbg con ion,end I oaf verings to as5"C"or better.
hereby authorize reveeenteUyes of ihls city to enter upon the ebove-menttaned raperry roc b- 9999
supection
Wrd purposes.
(We)soros to,eve,Indemnity and keep harmless the City of ClgeNrw a Inst liabilities,
Ind manic,costs and expenses which may In any way accrue against eek Chy in sequence APPLICANT - DATE
of ige grentlrg of Nle permit.
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