R-6515 PERMIT R_ 6 515
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408).7773228 PERMITEXPIRESIFWORKISNOTSTARTED
-
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS g44A
rr 6reok Apps to(bV Masi .
Sm6 fie: ZI 3�cv G Ln+nputt o
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA -
YES [-IM yea-I understand that a Class A
NAME ! roof assernbly is required.
A � )
NO. ❑ Irlida I.C.B.O.N
� 'J47 Ants � UI 1" V{Otw� EXISTING ROOF COVERING
ADDRESS pyQ rj
PHONE 1r3�' Q�J� NUMBER OF EXISTING COVERINGS
CONTRACTOR'S /
n ',-�-meTO BE REMOVED ` TO BE RETAINED
60IA
NADDRESSAME � DiQVI;, q—CITY a z P _677 R V �Bd&81L�K ( S� TYPE OF ROOF COVERING
a EXISTING
PHONE kpA 3) BUILT-UP ROOF ❑
LICENSE
NUMBER Z Z ASPHALT SHINGLES � O UCENSED CONTRACTORS DECLARATION
1 hereby affirm that I em Iloerumd under provfelons of Chapter 9(commentinDg wlfh Section WOOD SHAKES D
7000)of Divblon 3 of the BArsas and Professions Gods,end my license Is In full torte end
effMA 4 1999
License Clew C 33 Uc.Nu� WOOD SHINGLES
mber
Dale S /
Cor
Date OTHER(SPECIFY) By ❑
OVyNER-BUILDER DEFU_ -nON PROPOSED
I hereby affirm that 1 em exempt from me Contractors Ucenae Lew for the toilowing reason.
(Sec.7031.5,Boniness and Prdeadona Code: Any dry or Runty which requires a per mlf to
construct,alter,Improve,demolish,or repair any structure,prior to lfe lewanoo,also requires th BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that ha U licensed pursuant to the provle
of the Contracture License Law(Chapter 9(commenclnp with Section 7000)d Divlslon 3
Business and Proteaelons Coda)or that he Is exempt therefrom and the bade for the a egad ASPHALT SHINGLES
exemption Any vloladon of Section 7031.5 by any applicant for a permit sublsote the epplbent to
e dvll penalty of not more then Wo hundred dollars(5500).):
01,as owner of the property,or my employees with wages as their sole ccrnpensa0on,will do WOOD SHAKES ❑
the work,end the structure a not Intended or offered for Bele(Sec.7004,Business and Protons.
tiers Code: The Contractors License Lew does not sppty to an owner of property who bulks or SHINGLES ❑
Improrea maroon,end who does lurch work himself or through his awn employees,pravltled that
such Improvements are not Intended or offered for sale.If,however,the bulking or Improvement
Is sok within one year of completion,the owner-oulder will have me burden of proving that he did OTHER(SPECIFY) El
bulk or Improve ler purpose of sale.).
❑1,as owner of me property,em excivaively cont.01no elm l lcenaed contractors to conal 0
me prolact(Sec.7004,Business and Professions Code:The Contractors Ucense Lew dose ret PROVIDE LC.B.O.REPORT NO.
app toenownerctprapartywho Wilcisorlmprosestherson,arkwhocan"mtorsuchpmjeM
with a contracrer(s)licensed pursuant to me Contractors License Lew.
❑1 am exempt under Sec. ,B&P.C.ler this reason PROVIDE MFGR. INSTALLATION SPECS.
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penaky of penury one of the following declaration:
❑1 have and will maintain a Certificate of Concent to selbin lure ler Workers Compensatlon, Building
_
an prWded ler by Section 3700 of the Labor Code,ler the performance d the work for which this 2�J )v�
permit is Issued. 013 Seismic
I have and will mel pert Worker's Compensation work
Insurance,as rmit W is by Section 3700 s
me Labor Code,for nc performance and
of the work tar which this permit b issued.My Workers x)J
Compensetlon Insurance carrier end Policy number are:
t--a�— TOfe 2Gg,
Carrier 415. PolloyNo. �LZ O� 8r7L,J PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C{]
(This section need not be completed It the permit a ler one hundred n dolle (5100)or lees.)
I certlty that In the performance of the work ler which this permit is Its,ad 1 shell not emW 0'
any person in any manner so as to become subject to the Workers'Compensation Lowe of Celli All II shall be inspected prior to any roofing material being
'orale. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE a APPLICANT:rs'Compensation
atter making
kmg ale f the Lab d o e,youu met faamwth co oma Applicant understands and will comply with all non point
subject to the 'Com anmter rkNsbns d the Labor Code,
with such provislona or this permit shalpbe deemed revoked. sOUrce.regulations.
I certlfy the)I have read this application and elate that me above Information b correct.I epee '
to compywlfh all cry and county ordinances and elate Iowa relating to building construction,end All roof coverings to be class"C"or better.
hereby authorize representbibes of this dty to enter won the ebw nnentloned property for In. �///j ,s ,(n/ L --r qC�
epeotlon purposes. Q�jls.ClX �LC�C CJ— / U 1
(We)agree m save, Intlamnlfy and keep hartnlees the Clry of Cupenirw against IIebIlXles,
ludpmenta,costond expenses witch may In any way accrue against saidyIn consequence SIGNATURE OFAPPLICANT DATE
of the granting at this permit.
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