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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