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R-6636 or PERMIT APPLICATION FOR CITY of CUPERTINO NUMBER R" 6636 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 _ PERMIT EXPIRES IF WORK IS NOT STARTED . WITHIN 180 DAYS OF PERMIT ISSUANCE O. WI HIN 1 FROM LAST CALLED SSUA INSPECTION. O BUILDING ADDRESS �^ 1RESIDENTIA1_ COMMERCIAL - OTHER OWNERS HAzAgvous FIRE AREA VES ❑ It yes sser"ris mq that a Claga A , .NAME /�(WI�Lh ��JYN�4 roof asserroly is required. ^ NO ❑ Initlal LC.B.O.N ADDRESS ��'( EXISTING ROOF COVERING PHONE 5 2 D -7—i•••i—��S NUMBER OF EXISTING COVERINGS ✓ f CONTRACTO NAME R'S ,, n ♦ R BE MOVED TO BE RETAINED ADDRESS �t�, q TYPE OF ROOF COVERING clrr a ZIP 6 QAAA d�I. ! EXISTING PHONE 7 BUILT-UP ROOF ,. - ❑. LICENSE 3 NUMBER 25 ASPHALT SHINGLES ED/ LICENSED CONTRACTORS DECLARATION I hereby affirm that I ern fico sed under proviskKm of Chapter a(cornnnncing with Section WOOD SHAKES 7000)of DM.lon 3 of the Business and Professions Code,and my license Is In full force arc effect. WOOD SHINGLES ❑ Llcenee Clens Uc.Number , / .,,,�_��-.-.--.-- OTHER(SPECIFYj,. ❑ Date Conim'or �L OWNER BUILDER DECLARATION I hereby affirm that I em exempt from the Contradoes License Law for the folioMng reason. PROPOSED (Sec.7031.5,Business and Professbne Code: Any city or county"Ich require,a permit to I• JUN 2r 1999 U mminct,suffer,Improve,demolish,or repair any shucture,prior to Its issuance,also requires me BUILT-UP ROOF lJ . eppJcam for such permit to 110 a signed stalement met he Is licensed nt puraueto the provolone of me Contractors Lketae Lew(Chapter 0(commencing with Section 7000)of Division 3 d the Busme.end seemed Professions Code)or that he Is sed therefrom and the basis for the alleged ASPHALT SHINGL ❑ exemption.Any violation of.Sectlon.7W 1.5 by any applicant for a permit sublecis me applicant to 4r a civil early of not more men five hundred dollars($500).): ( `iy_— E]1.as owner of the property,or my employees with wages as their sde compensalon,will do WOOD SHAKES the work,and the structure Is not Intended or offered for Bala(Sec.7044,Business and Prof". alone Cade:The Conbactare License Law does not appy to an owner of property who builds or WOOD SHINGLES - ' Impr thereon,entl who re does such work I irelf or through his mpbys own ees,provided that ❑ such Improvements are not Intended or offered for sole.if,however,the building or Improvemem Is sold within one year of completion,the ownerbulder will hese the burden of proving that he db OTHER(SPECIFY) ❑ ISO not build or Improve for purpose of sale.). - ❑I,as owner of the property,am exciusfvety,concocting with licensed contractors to construct the project(Sec.7044,Business and Promifflons Code.The Contractor's Ucenas Lew does not PROVIDE I.C.B.O.REPORT NO. apply to en owner of property who bulics or l rmroves thereon,and who contracts for such protects with a canmctogs)licensed pursuant to me Contractors Ucensa Lew. PROVIDE MFGR.INSTALLATION SPECS. I am exempt under Sec. ,B&P.C.for this meson o«tror Data WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION, PERMIT FEE ' I hereby affirm uMer penalty at perjury one of me following Eedaradon: �� /f_ ❑I hese end will mairmam a Certificate of Consent to seibinsure for Workers Compensation, ,60 Buildin ea pr Wiled for by Section 3700 of the labor Code,for the performance of the work for which this �r, Building c947-01) lIaisoetl. "f9q . z7 I�� Seismic arc will maintain Workers Campsnsabon Ineuntnce,as required by Section 3700 of ZIAO the bar Code,for me Ixerlormenca of the w for which this pamnit Is Issued.My Workers" -/1��/�y� Comrmi: ion lnsumLtcee�cy�ber am: Total s 20 Carrier J�'•ry�`' Policy No. �O•� `� PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.CQ (This section need rod be completed H me permit Is for one hundred action;($100)or less.) ` (� Z 3 ' I teddy that In the performance of the work for which cols erm0 le Issued,I shell not employ any person In ny men er.o as,to become euaed t th tare Co ath tlon Laws of Call All roofs shall be inspected prior to any roofing material being forma. - installed. If a roof is installed without first obtaining an Date - 1 - Applicant inspection,I agree to remove all new materials for inspection. NOTICE f1b APPLICANT: If,eller making this Certificate it Exemption,you ahoald become Applicant understands and will comply with all non point sub)ec1 to me Workers'Compensation prm alons of me Labor Cade,you must bnhwith comity PP P Y M, erx:h provision.or this,Permit Mao be deemed revoked. - source regulations. I candy Mat I neve read this application and state met the above Information is correct.I epee to comply wlm all city and county ordinances and state lave totaling to building construction,end All roof Cover' gS to bQ class or better. hereby authorize representatives of this city to enter upon the alc v morboned property for In- apectlenpurposes. c. �= 9 (Wa)agree t0 have,Indemnly and harmless the harmlee City of Cupertino seedbed Ilebllltlae, • J • judi mente,costs and expenses which Trey In any way accrue against said City In consequence of the grand,;of thea permit. SIGNAT RE OF APP ANT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY