R-6567C `
J
0
PERMIT R- 6567
APPLICATION FOR CITY of cuPEHTwo NUMBER
INSPECTION DIVISION PERMIT XPIRATION
REROOF PERMIT (408)777-3'2'28 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS 2p'}2la
ISS?Bo(�D/NG PIA 2o}ISt J2q•430
-try" Z T C�oP
RESIDENTIAL�COMMERCIAL OTHER
OWNER'S
- HAZARDOUS FIRE AREA
_
• ''tom 1 ' A
YES 11R yes — I urWerStand Mat a Class A
NAME GAQ_DN.I.)VIL'LJJ LPD/L4C,P, f'T �'1<SpG.
roof assemdy is required. .•
NO ,/Initial I.C.B.O. tl
EXISTING ROOF COVERING
ADDRESS
PHONE '— Z I
NUMBER OF EXISTING COVERINGS Lei
CONTRACTOR'S
T
NAME In &/J.41SSA-n-IGe ii "it(�(L-�IAiG CO. 1AIC
TO BE REMOVED I/ TO BE RETAINED
•
ADDRESS
clryazIP -�Q2- LI,0Co�A) t/P S.T. �tSlz
TYPE OF ROOF COVERING
EXISTING
—
PHONE 6
BUILT-UP ROOFLICENSE ❑I —i7
5'59 --36 sX P 3 31 (
NUMBER ;
ASPHALT SHINGLES ❑
_ l
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am Ikeneed under provisions of Chapter a (commending with Section
WOOD SHAK
7000) of Division 3 of the Business and Professions Code, and pa In Ifu a lyr�; and
effect. P '/11 /
3
WOAD SHI S ❑
Ucwse Class cl:lc± Q Lk. Number S S q T 3�6
a
/ /�
Date �f�/49 Contractor 9AU-S l io_ ISAtF� Al + o ,
OTHER ( IFY)q
OWNER -BUILDER DECLARATION
P #4),
'
I hereby affirm that I em exempt from the Contractale LfoLe
enee w for Me following reason.
21
(Sec. 7031.5, Business and Profen sfone Code: Any city or county which requires a permit to
coratmd, after, Improve, demolish, or repalrarry structure, prior to Its Issuance, also requires the
apocant for such to We a signed statement Net he Is licensed to dib
BUIL - OOF 11999
permit pursuant provisions
the Contractors License Lew B
of (Chapter (commencing wOn Section 7000) of Division 3 of Me
Business Professions Code) Met he b
o
and or exempt therefrom end Me basis for me alleged
exemption. Any vkletlon of Section 7031.5 by any applicant for a permit subjects the applicant to
ASPHALT SHI
a civil penalty of not more than Me hundred dollars (S500).):
sAM
SWAM
WOOD -•�VLN
❑I, as owner of the property, or my employees with wages as Moir We compensation, will do
SHAKES -
the woM, will Ne structure Isnot Intended or offered for sale (Sec. 7044, Business and Prolss-
���
slons Code: The Conts ractors Ucense Lew does trot appy to an owmr of property who builds or
improveereon, "who
WOOD SHINGLES C-13
thanddoes such work himself or through his own employees, presided diel
Pmprovement
dreX
such Improvernenb ere not Intended or offered for solo. If, however, the building or
Is sold within one year of compbtlon, the ownerWlWer will have the burden of proving Net he did
OTHER (SPECIFY) 13rest
bulk! or Improve for purpose of sale.).
❑ 1, as owner of the property, em exclusively contracting with licensed contractors to owetmct
the project (Sec. 7044, Business and Professions Code: The Contractors Ucenso Lew does nest
PROVIDE I.C.B.O.. REPORT NO.4:Srir9 jM Z- 2'
appy to an owner of prop" who fou lids or Improves thereon, and who contracts for such projects
with a contrectogs) licensed pursuant to the Contractors License Lew.
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 am exempt under Sec. ,B & P C. for the reason
Owner Deb
WORKER'S DECLARATION
APPLICATION DATE
VALUATION
P IT
I 1 ho affirm under Penalty of perjury ono of the following dura for ion:
urywe of
❑ neva erxl MII maintain a Consent to self -Insure for worker's Compensator,this
aA ay
•
for by Section 3700 Lobar Cade,
WND
Q i
of the ab r
0l the for the performance of the work for which Mie
as prov" is
p rmff Issuetl.
have entl will maintainrf Worker's C Insurance, ee required by Section 3700 0l
"1
S/��/^
�� �
I IC
the work for
r Code, for iha performance of the work for which Mb permit gf�fasued.M/v. WG.orker's
anssdon Insurance cerrler'jentl��Po�licy number era: £7C/v lll/F'r'
/
tai
coIry X76
PERMIT AUTHORIZATION
DATE
Co., illy -f 4AlOfta' --�OP-arpNo.t, r-Z'yr/t7�V
CER FICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed H the permit Is for ons hundred dollars ($1 W) or lose.)
SIPE
I cantly that In the performance of tiro work for tich this permit Is Issued, I anal not employ
All roofs sh II be inspected prior to any oofing material being
installed. If a roof is installed without first obtaining an
only parson In an manna ep as 1p becpme sub t a Me works s' p su Le of can-
form —
Date 1/99, Applkam
Inspection, I agree to remove all new materials for inspection.
Non TO AP CANT: it eller maklh le Certificate of Exempdon, you should become
subject to the Workers Compansstbn pr s a the tabor Cade, you must forthwith comply
Applicant understands and will comply with all non point
PP P Y P
with such provisions or this permit she deemed remkad.
Source regulations.
I cor fly that I have read this application and state Mat the above Information Is correct.! agree
to comply with all coy and county ordinances and state laws reoatlng to banding constructor, and -
All r OVeringStO CI' better.
hereby euthodze representatives of this city to enter upon the above-mentloned property for In-
sp
d l 9
(We) agrpeeee.
(We) agree tos save, Indemnify and keep hart Nees the Cry of Cupertinoape not IIabIINee,
in City In
GN URE OF APPLICANT DTE
Jutlpmenb, costa and expenses which may airy way accrue epelnM said consequence
of the granting of this permit.
PRE -INSPECTION:
PLYWOOD: V
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