R-5921 P9 I
PERMIT R_ 5 9 L
APPLICATION FOR CITY OF CUPERTINO. NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT 0 408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS
01-3 eRESIDENTIAL L COMMERCIAL OTHER-
OWN ER'S
THEROWNER'S HAZARDOUS FIRE AREA
YES ❑. - Itym-lunderstandthata ClassA
NAME o/J2r�8& �S 6 r0 / Tool i9 rfsquirBtl.
n/�//1 ����//77 l / NO ❑. Initlet I.C.B.O.a
ADDRESS Z2 9 zz 9/vers 1 / �/ �l/� fC-6- EXISTING ROOF COVERING .
PHONE Q SaSo NUMBER OF EXISTING COVERINGS /
CONTRACTOL i -
NAME T S TO BE REMOVED 70 BE RETAINED
ADDRESSTYPE OF ROOF COVERING
c 7v a zIP • q
EXISTING
PHONE 352 - J2-3-3 BUILT-UP ROOF
LICENSE S
NUMBER _ - ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provalons of Chapter 0(commencing with Section WOOD SHAKES
]WO)of dvlslon 3 of the Business and Professions Cade,and my license is In full force Oita
effect. C 2 WOOD SHINGLES
License Class C-3 9 Lk.Number -/✓ � E]
Date
OTHER(SPECIFY) El .�_
'
OWNER-BUILDER DECLARATION Cl
hereby affirm rhes art exempt from the Contractor's orLicemiecoup Law for the vresareason. PROMED
(Sec.hereby
, irm If t ea ark exempt
Professions Cede: Arty city or county which requires blowing permit to
construct,alter,Improve,demolish,or repair arty structure,prior to its lesuance,also requires the UWLjL1UAjWF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provblons V IY 1
of me Contractors
Uceose Law(Chapter B(commencing with therefrom
and]000)of for
3 of the
Business and Yalat°bnf Coda)«that he Is exempt antfora entl the belle for the applicant
to
ASPHALT$rIfJGLES _ ❑
a civil en.Myf not on of Section hundred
d arty applicant for a permit subjects the applicant to C l Y Ur VVn k-r r t u
e caval penalty of not more men five hundred tldlare(5500).1: WOOD SHAKES
❑I,es Owner ofineproperty,or to d"or offered
wage°(etheirsets campessa and
will do
the worn,and the structure Is not Intended or offeretl for sale(Sec.]044,Business entl Pmfae-
mans Code:The Contractors Ucense Law does not apply to an owner of property who bullas or WOOD SHINGLES El
such
thereon,and who does such work himself or through has own employs",proOded that
such Impmvemenu aro not Intended or offered for sale.If,however,the bulking or Improvement
is sold within one year of completion,the owner-bulkm wla have me burden of proving met he did OTHER(SPECIFY) ❑
not build or engrave for purpose of sale.).
❑I,as comer of the property,em exclumvOy conbecsang with mensed contreolare to construct
the project(Sec.7044,Business and Professions Code:The Contractors Ucense Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bulks or Improves merean,and who contracts for such projects
with a conbe )licensee pursuant to me Contractors License taw. PROVIDE MFGR.INSTALLATION SPECS.
I em exemptemptantler Sec. ,B 8 P.G far cola reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of penury one of the following declaration; I c s
11 hese and will maintain a Cerflllcate of Consent to self-Insure for Workers Compensation, Building
as provided for by Section 3]00 of me Labor Code,ler the performance of the work for which this
permit is lasued. G �f / �' Co
Seismic
Cl I have and will maintain Workers Compensation Insurance,as required by Section 3700 0l
-the Labor Code,for the performance of the work for which this permti Is Issued.My Workers
CompensationlnsumrX.recarrier ar{��j��,,Iic-y mb1ere: � OO Total tyg.
Certle h w i�1L//V /3K f/SIO7 /So
/I1��/�d hFROM WO PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C{] T _
(This section need not be completed it dre perndt Is ler one hundree tldlen(SIM)otiose.) V LqO
I certuy,that In she Performance of the work for which cob permit b Issued,I shell not employ R
any person In any manner so as to become subject to the Workara•Compensadon law°of Calif. All roofs shall be inspected prior to any roofing material being
fornl°' - 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 making tie Certificate of Exemption,you should become Applicant understands and will comply with all non int
subject to the Workers'Compeneatlon provlelons of me Labor Code,you must forthwith comply pp P Y PD
with such provisions or this permit she0loa deemed!revoked. source regulations.
I cerhfy that I have read this application and sate met the above Information 1°correct.)agree �(j
to comply wins all city and county ordinances and state laws releung to busking construction,and All roof CO F1' gS to be class`l for better..
hereby authorize representatives of this city to enter upon the abo e-ment"d property for In- Y
specuon purposes. / —/a—py-
(We)agree to save,Indemnify and keep hermless.the City of Cuportino against IIailWes, lD
lukgmenta costa entl expenses which may In any way accrue against said Gty In conasquen a SIGNATURE OF APP CAN DATE
of the grendng of this permit.
i 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