R-6684 PERMIT R_ 6684 ,
APPLICATION FOR CITY OF CUPERTINO - NUMBER.
INSPECTION DIVISION PERMIT EXPIRATION
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. .
BUILDINGADDRESS
X04 .4rd0 �• �f
,,/'t, LL 'BLVD. RESIDENTIAL)`X/
COMMER61AL OTHER
OWNER'S • HAZARDOUS FIRE AREA
y
�µ�� U VES ❑ Ifyes—(understand Nata ClassA
NAMES-+`�e'^ VAI I '-`oRR r'.LL.A roof assembly Is required.. .
tµ1 ' L NO ❑ Inlnal I.C.B.O.+I
ADDRESS �0 `�U �• ��� �1V� BLVD• P EXISTING ROOF COVERING .-
PHONE ' 0 U 1 — 0 IO{O NUMBER OF EXISTING COVERINGS I N�
_ CONTRAC OR'S - - -
06 flg/� TO BE REMOVED To BE RETAINED
/9
... NAME 1` r lA
ADDRESS II / ({��'� TYPE OF ROOF COVERING
CITY&ZIP—`ag p� qq / TL;I Lo5('emr
I` C— 2_1 '_ 1 1q7. EXISTING
• PHONE BUILT-UP ROOF ❑
LICENSE q [�Q
NUMBER L. 7 1 ASPHALT SHINGLES
UCENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed undx provisions of Chapter a(corm ww with Section WOOD SHAKES El
of Di,raon 3 off.thea Business ark Profession,Code,and my IlDsm,is In full force ark
License �/ �_ u 72-7!ill WOODSHING SIEi
- R(SPECT ❑
Date Doniadar JUL 12 1999
- ER-BUILDER DEC TION
I hereby affirm that I am the Gannet ken,, or the lo,owing
(Sac.7031.5.Business and Protests y dry o n y which requaae a permn to
conal Car.Improve,demolish,or repair airy structure.Prior to Its issuance,also,requires the BUILT-UP ROOFEl
far each permit to file a sigrrod sed su
statement Mat he le licenpurant to the provisID s 1�
d.the Contredo',License Lew(Chapter g Section 7000)of OMMon 3 of it,
. Business end Prd„atom Code)or Mat he Is exempt therefrom and the basis for the alleged ASPHALT SHIN
exemption.Any violation of Section 7031.5 by any applicant for a permit subject•the applicant to
a cr4 penalty of not more tush five hundred doAar,(5500).):
I]l,as owner of the property,or my employees with wages as Melr sale comperustkn,wW do WOOD SHAKES ❑
the work,and the structure is not intended or offered for into(Sec.7044,Business ark Proles.
sons code: The Contractors License Lew time not apply to an mrner of property who build,or WOOD SHINGLES ❑
Improvthereon
es ,ark who doe,such Noi
work mself or through his own employees,pnded Met
such Improvements are not Mtentled or offered for sale.If,however,Me building or rnprovement
Is add within one year of completion,the owner-builder M,he”the burden of proving that he did OTHER(SPECIFY) El
bund or Improve for purpose of Bele.).
.❑I,as owner of the property,em"cluahasty connecting with licensed contrecurs to construct _
the project(See.7044,Business ark Professions Code:The Connectors License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of Property who bulks or Improves Mereon,and Mro connects,for such projects
WM a wntractoq,)licenced pumuent to the Controctare Ucen,e Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B S P.C.for this reason
Owner Dau
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty,of perjury one of the lolldwtrq declaration:
❑1 have and will maintain a Certificate of Consent to self4nmure for Worker,Compensation, Building
es,prov sis for by Sacllan3700 o1 M,Labor Cade.for nu performance theworkbrwhich Ml, /, /h g
m le Issued. /] G�1 Vt�/
Pe(LA.f have and will Ins pan Worker,Cee work on Insurance,es,repulsed by d.My 3 Worker's of I —1 s o (ti SBISmIC
IRs Caen Code,for Me performance of Me work for which Mu pertnit Is Issued.My WorRere
Camp,rreatbn Insurance car;Ler and Policy number are: � Total �
Carrier ti
Policy No. i 1 — 106ggo
`v PERMIT AUTHORIZATION DATE
CERn FIC OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ _
(This"don need not be completed If the permit is for one hundred dollars($100)or Ines.)
I certify that In the performance of the work for which MI,permit Is Issued,I shell not employ
any Person In any manner w as to become subject to the Workers'Compensation Law,of Call. All roofs shall be Inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Z Appocam inspection,I agree to remove all new materials for inspection.
Nonce TO APPLICANT: II, star meklrp W, tricots of Exe ,you should become Applicant understands and will comply with all non point
eublect to the Workers'Comp of lour a must bdhwiM comply
with such provietons or MIB permit shell be d mad revoke SOUfCe fagUlBhOnS.
I certify Met I bare read this application and elate Met Me above Information la correct.I agree
to comply with all dry and county ordinances and state Issue Meting to building conetrudkn TO yefmgS CO be class"C"Or better.
hereby authorize repreaentalNae of Mle dry to enter upon the above-mentioned props r Ion
spactbn purposes. ,v
(WM agree to save, Indemnify,end keep harmless the City of Cupertino a eine leblift1n, G
jutlpmenu,ccau and expenses which may In"way accrue against sold Cly In cone nce
or the granting of this permit. SONTU FAPPLICNTATE
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