R-6245 APPLICATION FOR CITY OF CUPERTINO NUMBER R" 62 4 5
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (doe)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
al#15r oa-A-4 Oil
RESIDENTIAL COMMERCIAL OTHER—
OWNERS
THER OWNER'S HAZARDOUS FIRE AREA
CYES Cld yes—I understand that a Class A
NAME 'S roof assemby is required.
NO ❑ Initial I.C.B.O.A
ADOREss � EXISTING ROOF COVERING
PHONE -A S 3 9 NUMBER OF EXISTING COVERINGS /
CONTRAC 'S / .
TO BE REMOVED O BE AINE
NAME
ADDRESS _
CITYB ZIP — EXISTING MAY 2 41999
PHONE 5/0 • 94— 7172-- BUILT-UPROO ❑
SE
NUM ER �I \ ASPHALT SHIN
LICENSED CONTRACTORS DECIARATION
I hereby affirm mat I am licensed under provisions of Chapter a(commencing with Settlor WOOD SHAKES �7(`
700D)of Division 3 of the Business and Professor,Cotte,end my licanee Is In full farce and
affect. WOOD SHINGLES
License Class C� • Uc.Number6-9// 74 ❑
OTHER (SPECIFY) E]Date � Contractor
OWWNER.BUILDER DECI-ARATI1514 PROPOSEDI/ p �[
I hereby affirm that I em exempt from the Contractors License Law for the following reason. 1.p r`
(Sec.7031.5,Business and Professions Code: Any city or county which naqudr e e permit'Io III
c hum
ed.after, or repalr any structure,pror to He issuance,a requlree me BUILT-UP ROOF ❑
applicant for such Permit to file a signed statement that he Is dicerued pursuant to provLelon.
of has Contractions Ucenae Lew(Chapter 8(command with Section 7000)of Dr, n 3 of the
. Bualne.a and Profe.skos Cotte)or that he Is exempt therefrom and the basis for alleged ASPHALT SHINGLES El
exemption. viclelkon of Seetlon 7031.5 by any applicant for a permit subjects the nt
e civil penalty of not more than live hundrod debars(S500).): WOOD SHAKES❑I,es owner of the progeny,«my, employees vim wages as their action,w111 do El,A.
the work,and Ne structure 15 not Intended or offered for eels(Sec. 0,B end Proles- ���•y
flora Code:The contractors Ucense Law does rot apply to an of p builds« WOOD SHINGLES
Improves thenen,entl not does deco roffe elf ala or through he r. ,p ked that El
such Improvements are not Intended or offered hi for fele.II,however,toe ng or P dead
is eek wlNln one year of completion,the owner. Ikerwipfte thaburde I proving that he did OTHER(SPECIFY)
cwt bulk or Improve for purpose of adds..
❑I,afowneralthe roperty,emexc yto wall edcontra onaloconmtnwl � �f,/�
the project(Sec.70l uslnesf and Prof rm C at r.Utero Lew does cwt PROVIDE I.C.B.O.REPORT NO. 2.7.
apply to an
owner of pr arty he His or lm the ,an o contracts for such projects
with a contractors)I need put ant to the neons ease Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt u r Sec. ,B&P.C.M this panda
owner Data APPLICATION DATE VALUATION PERMIT FEE
NER'S COMPENSATION DECUBATION
I hereby affirm under pens 1 perjury ono of the fallowing federation:
❑d have and will maintain a(Nrtlllcale of Consent to.elf-il a for Worker.Compensallan, O� Building/
as provided for by Section 3700 of .Labor Code,kr me soft mance of no vatic for which this
permit Is Issued. 61A 41/q-/ r�"��
/ V
I p d have and will maintain Workers C«npre00
eneatlon Insunce,as required by Section 37of / Seismic
aha Leber Code,for the performal of the work for which this permit Is sued..My Workers
/ !
Congysmntl n Insurance canter arfi Polity number are: .s�r� Total
Canter Policy No.W ff _ 4 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NW)o
(Tole settler roved not ba completed H the permit Is for erre hundred dolens($100)or less.) -
I certify that In the Performance of the work f«which this permit Is e.ued,I shall not employ
any person In y manner so as to become subjeq to ih re Compans kit Laws of call. All roofs shall be inspected prior to any roofing material being
fornia. installed. if a roof is installed without first obtaining an
Date Appllcant inspection,I agree to remove all new materials for inspection.
sub7jeed m dif�wAPPLICANT:
ars�Co If,
nselioaftero provIslonthis
s oGeld
f ill boof oot you est should become Applicant understands and will comply with all non point
pe P you must forthMm comply
with such provisions or this permit ehelCbe tlaemetl revokatl. SOUTCe regulations.
I certify that I he"reed the appdicill acrd elate that the above information Is correct.I ague
to comply with all city and county ordinances and stale ewe relating to bulclig constructer,and All roof toes=in lass rbetter.
hereby authorize representatives of this city to enter upon bw above-men okmyd property for m-
spacdon purposes. p /�
(We)agree to anis,Indemnify and keep harmless the Gly,of Cupertino against liabilities,
ju menta,costs and expanses which may In any way accrue against eek City In consequence SIGNATURE OFAPPLICANT DATE
of t e granting of the it.
perm
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