R-6416 PERMIT
-APPLICATION FOR CITY OF CUPERTINO NUMBER R" ' 6 416
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3226 PERMIT EXPIRES IF WORK'IS NOT STARTED
i' WITHIN 160 DAYS OF PERMIT ISSUANCE OR
-�' 180 DAYS FROM UST CALLED INSPECTION.
. -BUILDING ADDRESS
r.
� , gJfd l 'f
' Z E w ES T -j' R. RESIDENTIAL COMMERCIAL OTHER
OWNER'S
YES ❑ R yes-I understand thud a Class A- -
NAME LyNt3 e:6 QQ.:Le. roof aseemlbly is required.
/ NO V11 Irshal I.C.B.O.#L
ADDRESS S [ A - - EXISTING ROOF COVERING
PHONE-4jnE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S (� 1^r CO _
NAME Re.,OAISSAnK'� I>Onp'13(n C _�, TO BE REMOVED
� TO BE RETAINED
ADDRESS1 /� _ TYPE OF ROOF COVERING
CITY.&ZIPx-241— I21r ) 'COLu Ade- S ,, gS11 EXISTING
PHONE Ll O!6 q + : BUILT-UP ROOFLICENSE
- ❑.
NUMBER 559 3 6 ASPHALT SHINGLES ❑
DCENSED CONTRACTORS DECLARATION
I hereby allirm that I em licensed under pnuvlalma of Chapter 8(commencing with Section WOOD SHAKES
7000)of Division 3 of the Buslnee,and Profession,Code,and my license i,In lull force and
effect.
LfoeneaGesa �%3 Ci � — WOODSHING ❑
Lic.Number
Date con OTHER(SPE )
Or I OWNER-meCov IARAnse PROPOSED
ON
hereby affirm that em exempt from the ors License Lew Iw the following neem.
(Sec.7031.5,Businem and Profession.Code: Arty dry w county which requires a permit to
construct,alter,Improve,demolish,or repair any structure, rfortolble.uance.aborequlresthe BUILT-UP ROOF ❑
applicant for such permit to fte a signed statement Met he P,Bcensed pursuant to tis provblons
. of Me Contractors License Lew(Chapter B(commencing with Section 7000)of DNISIm 3 of the .x
Business and Professions Code)or that he Is exempt therefrom and the bests for Me alleged ASPHALT SHINGLES G 2�2'
exemption.Any videtlon of Section 7031.5 by any applicant for a Permit sulcocts the applicant to /�
a civil Penalty of not more then five hundred"lam(fsoo)J:
❑I,as owner of the property,w my employees with wages as th mpeg4e will0q(�1 OOD SHAKES ❑
the work.and the structure is not Intended or opened for sale(Sec 7 Susina44 mf-u C+L�S s, r
slons Code:The Cmtrador,Ucanse Lew dove rot appy to an k prope Vi Ida or ODD SHINGLES
Improves thereon,and who does such work hIII I or through his b ployees, roWded that ❑
sum Improvemens are not Intended or olleretl for sale.If,however, Ildirg w Improvement (]
Is sold within one yearof ccmpbtlm,the ownor.bullderwlllhavathe - ep olpro.i1pbiAthodml�J HER ❑
not Wild or Improve for purpose of sale.). - r 1%IA
❑I,as owner of the property,em exduslvey contract wlthlken contractors to construct
the project(Sec.7044,Business and Probsslons Cade:The Contr License law does rot P OVIDE I.C.B.O. REPORT NO.
apply to an ownar of property who builds w improves thereon,and who tmde for such projects .
with a contractor a)licensed pursuant to Me Contractors Dcenee Ia 1
❑1 am warept under Sac. BI n PROVIDE MFGR.INSTALLATION SPECS.
Omar _ Data
WORKER'S COMPENSATION DECUBATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of camury one of Me following declaration. ,
❑1 have and will mailmaln a Catllflcate of Consent to self-Insure for Workers Compensation, Building /)
as provided for by Section 3700 o1 the Labor Code,for Me performance of the work for which Mie
siesued. /Z'2'�q� $�'�.Lj$ Seismic
have antl will the performance
Workers f the w Compensation which this pe required by d.My 3700 of
e L Cade,for the pedormwroe al the wwark iw which this permit b issued.My Workers
Compa�,re/�9`If n Ineuonce center en Pd Icy number are: /�sA� Total /
CerrerV/C(l►I✓Of//f��15UR.9<1[QPOII yNo._GlC2—004 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION H e Per INSURANCE N.C.] ^ ^�
(This section need not be completed n the permit Is for we hmWed defiers(f 100)or lees.)
I certify Chet In the performance of the work for which this permit is Issued.I shallnet emplry,
arry person In any manner so a,to become sult1w to the Workers'Compensation Levee of Calk All roofs shall be inspected prior to any roofing material being
fonnle. Installed. If a roof is installed without first obtaining an
Date Appllcaht - Inspection,I agree to remove all new materials for inspection.
Nonce TO Arkers' Pompe after makingthisUfa I ale of me,you must fortyou hwith�mty Applicant understands and will comply with all non point
eubl O to the Workers'Compensation roWelms al the Labor Catle,
with such proNelons or Mb Perms shall be deemed revoked. source regulations. '
I cerffy that I have read this application and state that the above information Is correct.I agree
to comply with all dry and county ordinances and state levee relating to bulking constriction,and ;1AT;ULRE:OF
COVerin �,r etter.
hereby authohse representatives of this city to enter upon the above-mentioned Property for In-
specllon purposes. 3/L Z
(We)agree to save,Indemnity and keep hennlee,the Cry of Cupertino against liabilities,
". of the gmn route and expenses which may In arty way accrue epeln.t mb Gry in consequence APPLICANT DATE
of the ents,cortg of thio expen
PRE-INSPECTION: OW PLYWOOD: IN-PROGRESS: fC
INSP.—DATE INSP.—DATE INSP. DATE
TEAR OFF INSPECTION: X BATTENS: FINAL
INSP. DATE INSP. DATE INSP.-* DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY '