R-6498 PERMIT
APPLICATION FOR CITY of CUPERTINO NUMBER R- 64 g 8
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
IBO DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
�oYES ❑ If yes—I understand chat a Clens A
NAME L roof assembly is required.
�-y NO ❑ Irifial I.C.B.O.Y
ADDRESS a�6�^3 X165%)LP-0`t' )Lp' EXISTING ROOF COVERING
PHONE o.5 3�bZ NUMBER OF EXISTING COVERINGS "111l e
CONTRACTORS
NAME � ��-l�'�) ZDoF. ix, TO BE REMOVED C�r� TO BE RETAINED
ADDRESSr,� icy TYPE OF ROOF COVERING
CITY&ZIP l�'� O t.�J.J'�c� � P\Ty ifs EXISTING
f \ "OLl3
PHONE l6S�D ) S—LGI.— Q11 BUILT-UP ROOF ❑
LICENSE ❑ _ /
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provlears of Chapter 9(commendrg with Section WOOD SHAKES
7000)of Dlvlsbn 3 of the Business and Professions Code,and my Ioense Is In lull force and
adrtd.
CWOOD SHINGLES_ I[C]
License ClansS �� Lk.Number -�b l0� OTHERI(SPECIFY 1'
Data t! •2k 9C1 Cbruractor �)rP\ P- !),� APk 2 8 1999 U
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am lariatfrom the Committees License Law for the following reason.
(Sec.7031.5,Business and Prolesalons Code: Any city or county which requires a permit to I - _
conilrucL tither,Improidemolish,or repdr any structure,prior to its Issuance,also requires the BUILT-UP ROOF
applicant for such permit to file a signed statement that he Is licensed pursuant to the proviaons 1
of the Contractai Ucenart Law Chapter g(commencing with Section 700(t)of Dlvlslon 3 of the
• Budnees and Professions Code or that he Is exempt therefrom and the basis for the alleged ASPHALT—SHINGLES ❑ '
exemption.Any notation of Section 7031.5 by any applicant for a permit sub)ects the applicant to
a chil penalty d not more Nen five twice dollars
C]1,a9 owner of Ne property,or my employees with wages as their We compensation,will do WOOD SHAKES
the work,and the structure Is not Intended or offered for sale(Sec.7044,Busmani entl Pmfas-
dons Cade:The Contractors License Law does rot apply to an owner of property who builds or WOOD SHINGLES
Improaes thereon,and who does such work himself or through his awn amp"",proi Net El
such Improvements are not Intended or offered for sate.ll,however,the builtlhg or Improvement
Is add within one year of completion,the owner-bulkier will have the burden of proving Mat he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of to property,em exduslvety contracting with licensed contractors to construct
the praect(Sec.7044,Business and Professlcns Cape:The Contractors Ucense Law does cwt PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Imprcvea thereon,and who contracts for such projects
with a contracepi Iicerni pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B&P.C.for this reason
Owner Dere APPLICATION DATE VALUATION PERMIT FEE
WOfiKER'3 COMPENSATION DECIARATION
1 hereby affirm underpenalty of perjury one of tier following declamation: �7�
❑1 have and will maintain a Certificate of Coherent to nefi4naure for Worker's Compensation, BUi ding`�
Its prwlded M by Sector,3700 of the Labor Code,for Ifer performance of the work for which this A Q
permit eleauetl. LI• •q� \ `t �� Seismic _/�.( Q
have end will meinteln Workers Campareratbn Ineumnce,rte requlretl by Sedbn 3700 0l 3 90
1 r Code,for the pehformence of the wark for which this parmlt Is Issued.My WoNere
Com tion Insurance carrier and Policy number are: 1 y` ^f Total
Canter 1)1L.�t1 611A PolayNk tQcf126k PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATON INSURANCE N.CQ
(This section read net be completed!If the permit Is lar one hundred dollars($100)or less.)
1 carry that N the performance of the work for which this permit Is Issued,I shall not employ
any person In any manner so ss to become subject to the Workers'Campenaanon Laws of call- All roofs shall be inspected prior to any roofing material being
fprn18 .-, ����� installed. If a roof is installed without first obtaining an
� �
Data�1_ Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Ce a of Exemption,you should becarn Applicant understands and will comply with all non point
subject to the Workers'Compansaton provisions d the Labor Code,you must forthwith comply PP P Y P
with such provisions or this permh shall be deemed revoked. source regulations.
I certify that I heart read this application and state that the above Information Is correct.I agree
to comply with all city and county ordinances and slate laws relating to building construction,and All roof coverings to be class or better.
hereby authorize representatives of this city to enter upon the eboe manffoned property for In-
spection purposes.
(We)agree to save,Intlemnity and keep ha miless the City of Cuportirw against IIebI1111es, '� Z�r911
judgments,costa and expenses which may In any way accrue against sdtl City in consequence SIGNA L PPLI NCA T • DATE
of the pending of 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY