R-6278 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R" 6278
INSPECTION DIVISION PERMIT EXPIRATION
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 ADDRESS
Z� � N 1�A►� ry l g PC) RESIDENTIAL " ' COMMERCIAL OTHER
OWNER'S / HAZARDOUS FIRE AREA
NAME ! m �U YES ❑ roof eweunderstand requ redt a Class A
NO ❑ Initlal I.C.B.O.lf -
ADDRESS 'ZZ'\F7"it(0 q"%1ANN\SEXISTING ROOF COVERING
PHONE TL� 1 - NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
�LT�� h-ANG liD „1(JL- TO BE REMOVED TO BE RETAINED
NAME�NA�SS #'-
ADDRESS TYPE
L1rJCOLTO AVg , .CD� 1�j)� TYPE OF ROOF COVERING
CITY 8 ZIP
W 1
/ EXI TING
PHONE l � —0 BUILT-UP ROOF El
LICENSE 5�r22!
NUMBER ASPHALT SHINGLES ❑
_b .To
LICENSED CONTRACTORS DECLARATION
I hereby affirm met I em licensed under provisions of Chapter B(commencing with Seddon WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In fuk force and
effect. cif WOOD SHINGLES ❑
License Class Lb.Number' q
II I�S'98 Q Jgfnly r�C� 64*1t OTHER (SPECIFY)
Date Contractor
OWNER-BUILDER DECLARATION PROPOSED �y
1 hereby affirm that I em exempt from the Convectors License Lew for the-folfowvhg r
(Sec.7031.5,Business and Professions Cade: Any city or count>rwli(cli requlres e rnYt ❑ ��
Construct,eller,Improve,demolish,or repair any structure,Prior to Its
ase
also, pe✓ea BUILT-UP ROOF
applicant for such permit to file a signed statement that he le licensed pwin4ni to theLploWe
of the Convector's License Lew(Chapter B(commenclny Writ Section 71X10)of DIM 3 of
Business and Professions Cade)or that he Is exempt mdrefrom aro me basls for the al eg ASPHALT SHINGLES ❑
exemption.Any NNatlon of Section 7031.5 by arc,applicant for a fproVubfect9h t t
e c[Al penally of not mora than five hundred dollars($50(1 ryLJ V 1 U _
[3 1.as minor of the property,or my employees with wopae as their sole companeation,will WOOD SHAKES
the w and the simcture is not Intended or offered for (Sec.7044,Business trhd Proles.
eons Code:The Contractors Ucense Lew does not apply to en ovmer of property who bunds or WOOD SHINGLES
Improves thereon,and who does such work himself or Ihmup11,41s am employees,provided ❑
such Improvements are not intended or offered for sale.If; e;_dibulidinggO
Is sold within one year of Completer,the owner-builder win head mbiwFdenol proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑1,as owner of the property,am exduelvely contracting with Ilceneed contractors to construct
Me proles(Sec.701 Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bulds or Improves thereon,and who contracts for such projects
with a commota(e)Ilcerued pursuant to the Contractors License Lew. PROVIDE MFGR. INSTALLATION SPECS.
❑I em exempt under Sec. ,B 8 P.C.for me reason
owner Cate APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECIARATION
I hereby affirm most penally of perjury one of the following declaration: /e
❑1 have and will maintain a Certificate of Consent to self-Insure for workers Compensation, Building d
as proalded for by Section 3700 of the Labor Code,for the performance of the work for which this 1 (J q
permit Is Issued. 11 �I� li� �I�/�I�� Seismic �=
&N
have and will maintain Workers Compensation Insurence,as requl red by Section 3700 of YJ
the Labor Code,for the performance of the work for which this permit Is Issued.My Workers O
Compensation Inemarco center end Polley number are: �y Total ( ,Uel
Center 01 F'UN� Policy No.IS 4- 3 PERMIT AUTHORIZATION DATE
CERTIFICATE EN EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This sectkm need not be completed If the permit Is for one hundred dollars($100)or lose.) (�
1 cerdfy mat In the performance of the work for which this permit is Issued,I&I not em loY
arty parson m any manner w as to become sublect to the Workers'Ccmpenssticn L of�I- All roofs shall be inspected prlor to any roofing material being
familial. installed. If a root is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPUCPNT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non Int
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP P Y PO
wlm such proNSWne or this pemIt shall be deemed reyoked. 'source regulations.
I canny met I hese read this application mW state met the above Information Is come ti I agree
to comply wish all city and county ordinances end state laws relating to bulkfing conmuctbn,arid All f verings to be class Or better.
hereby authorize representhllyes of this dry to enter upon the above-mentioned property for In-
ep purposes.
(Wi //I4�✓ ���� q,
(Wel agree to save,Indemnity whish
keep harmless the Gty of Cupertino against liabilities, I
ofJudgments,the gran costa tris permit. which they In any way accrue against said City In consequence IGNATURE OF APPLICANT DA E
of the granting of cols 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