R-6566 PERMIT
APPLICATION FOR CITY OF CUPERTINO . NUMBER R— 6566
INSPECTION DIVISION PERM XPI TI N
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.
BUILDING AD ESS3 . �U(LD/
2.A95
-4111,
11 GAZDeW MAMWL CT,
(cup
RESIDENTIAL COMMERCIAL OTHER—
OWNER'S
THEROW ER''SHAZARDOUS FIRE AREA
H -lfa
NAME GOA l2.Deou Vii-w Te—uAc.e. HA AssiI YES ❑ ao eassemb d Is�requiradd. G895A
NO Initial I.C.B.O.
ADDRESS �`f o EXISTING ROOF COVERING
PHONE 2.65 �' I - NUMBER OF EXISTING COVERINGS i
CONTRACTOR'S —n(1 /� ✓//
NAMERli AIS AAk'P_ OOt IrJG l r = TO BE REMOVED TO BE RETAINED
� NC..
ADDRESS TYPE OF ROOF COVERING
cmazlP2-2.92- L ww-noij S 9512.5 EXISTING
PHONE__ AOR�p—LLI `/)8 —0 6 G� BUILT-UP ROOF
LICENSE NUMBER S5 -1 3rD FXP: 3 3/ R// ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby allirm that I am licensed under provlslons of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Cade,erel my license Is In lull force anti
effect.
�-q—+-7/13'
ry WOOD SHINGLES EDUcanee Clew C.� � Lk.Number sJ`l�� �� ��
Date Contractor Oj41ss4W_,V_ L[Ylt•IMYor OTHER(SPECIFY) El
OWNER43UILDER DECI-FAAMON PROPOSED
I hereby affirm Met I am exempt Iron the Contractors License Lew for the following reason.
(Sec.7031.5,Business and Professions Code: Any dry or county which mquIma a pemJt to
conswcl,sitar,lmproe,demolish,or repair anystructure,prior to lie Issuerx:e,also requires the BU ROOF ElS8
applicant b such permit to file a signed statement that he Is licensed pursuant to the provlip"
of the contractors Ux,enee Lew(Chapter 9(commencing with Section 7000)of DPdeen 3 of the 1,^
Business end Professions Code)or Met he b exempt therefrom end the basis for the areged A LT SQ04ki^S
exemplen.Any violated of Sedlon 7031.5 by any applicant for a permit eublecte the applicant to —
a civil penalty of net more Men five hundred dollars($500).): D SHAKE
❑I,as owner of the property,or my employees with wages as Moir set@ compenealbn,will do , HAKE j ❑ 3 ,. R •���/
the work,and the onto U net Inse dec!Law or offered for me(n onmer of properBusinety
and Pmtaer 0 V JrIIN&iS�e(1 / ❑ ��,�w0/V`�
We"Cade:The Contractors License Lew does s nal apply to su owner of ip"a",who bulge or J J
Improves oeraan,srk who does each work himself or Through his own empeyeeor pmvmetl That [1
such Improvements one year
are not Intended M offered for sale.If,however,the bulking«Improvement J
n tokdorI prove for compmtlon,the owner-bulker will have the burden of proving that he old �JFiER(SPECIFY) ❑
not bulltl or Improve for Wrpose of sale.).
❑1,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Suainesa end Professions Code:Tho Contractors Uce se Law does not PROVID PORT O,ASFALI 9.3�12_-8'iL
apply to an owner of property who bulks or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contrectoes Umme law. PROVIDE MFGR.INSTA ION SPECS.
1 em exempt under Sac. ,B 8 P.C.for this reason
°wrier Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty W perjury one of Ne following d"Lauragon: (ri�w
❑1 have and will maintain a CertNicete of Consent to se8ansum for Workers Compensation, T BUlldln
as provitlatl for by Section 3700 of the Labor Code,for the performance of the work for which this /,l/���
ppm}Is leauatl. Af/ Se I
$j beta erM will maintain Workers Cortpanaeten Insurance,as required by$acted 3700 of _
t Labor Cade,for the performance of the wok for which this permit Is I Workers T 9
Compeneetlon Inayren��center entl Pol�iyc�y�number ere: r-�/P / � r TO
Carder Policy No. z•' �� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE N.C[]
(This section need not be completetl it the permit Is for one hundred co lars($100)or less.)
I certify Met In the performance of the wok for which Ihls permit Is leeued,I shall he employ
any person In any manner wane to become subject na Workers'Compe n o ll- All roofs shall be inspected prior to any roofing mate I being
forma. �i1�99 installed. If a roof is installed without first obtaining an
Data-,S Pd Appll�,t inspection,I agree to remove all new materials for inspection.
NOTICE AP CANT: If,after mekysg t cennicao of Exemption,you should became Applicant understands and will comply with all non point
subject to the Wokers'Compensedon prWl lie of the Labor code,you must forthwith compty
with suU proyfil or Me Perm11 shall deemed reeled. Source regulations.
I certlly,that I hero read this app icatkn end nate that the above Information Is correct-I agree
to comply with all city and county ordinances and Nate laws relating to bulking construction,and All r verings to e a _ r atter.
hereby authorize moresentelkyae of this city to enter upon the above-mentlonetl property for Ira
spoctkn purposes. /
(We)agree to says, Indemnity entl keep harmless the City of Cuparflno against Ilebllhks,
ju menta,coats entl expenses which many In any way accrue against and City In comequence
rof t a granting of lis parmh. S ATURE AP LICANT 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