R-6689 PERMIT R_ 6689
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT WORK IS
REROOF PERMIT (409)777-3228 PERMIT EXPIRES IF WORK IT INOT SSUANCE
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
l0� Sol' De.\4 RESIDENTIAL ` COMMERCIAL OTHER
OWNER'S ��//��ys I �x �/ HAZARDOUS FIRE AREA
NAME G�I��''� if t ArJ A C00�/ YES ❑ r yes I understand tired. Class A
roof essernhly B required.
g5dz3 No ❑ Ir1Mal Lc.e.o.x
ADDRESS \tJA�'g N W Ay . µoLt.lSV6� EXISTING ROOF COVV7ERING
PHONE (
06 J ��� ��5 NUMBER OF EXISTING COVERINGS -
CONTRACT(O�/1'S
NAME `—b A 6411",0C.g Coll 6e, • j �N G- TO BE REMOVED - � TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITYazIPZ-2°�Z LwCO�i� flVG , gS , R'S� L�
��,, F,:x1.SSlNS
PHONE `^��f`��'�-0ro� BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES
UCENSED CONTRACTORS DECLARATION -
hereby affirm that I am licenser under provisions of Chapter 0(commencing with Section WOOD SHAKES El7000)of Divislon 3 of the Business and Professions Code,and my license Is In lull force and A
enact.
WOOD SHINGLES ❑
Ucall Class `- ` Lk.Number '55111
Data '70-9°I Convector ��A SC1 MCf eoof10 OTHER(SPECIFY) . ❑
OWNER BUILDER DECLARATION P' ED
I hereby affirm that I am exempt from the Contractor's License taw for the following reason.
(Sec.7031.5,Business and Profesil Cade: Any city or county which requires a permit to
applicant.alter.Improve.to No
siorrepairartystructure,prior to Its Issuance,also eeq Lythe BUI COF
applicant for each prowl,to mo i signed lir amen,that he Is orlicensed pursuant al the pro+ls;the
of the Cartel License Lew(Chapter B(commencing with Section 7000)of DMalm 3 of the ry—C
Business entl Professions Code)or Chet he Is exampt therefrom entl the cal for Me alleged ASPHALTSHINGLESexemption.Any violation of Section 7031.5 by any applicant for a perm0 subjects the applicant to
adull penalty of not more than five hundred dollars(5500).): WOOD$HAKE$❑1,as ownerof the property,or my employees wiU we ea as their sole cow nsetion,will do the work,entl the structure le not Intended or offerer for sgets(Sec.7044,Business and Proles- L e7 99done Care:The Contractors License Law roes rot apply to en owner of property who builds orWOOD SHINGLESImproves Hereon,and who dose such work himself or through hie awn employees,provided metsuchimproements are not Intended or offered for sale.H,howeveq the bullring or Improement
Is sold will one year of completlon,the owner-builder will he"the burden of prodrg that he did OTHER(SPECIFY)
not build or Improve for purpose of sale.).
❑I,ee Avneroftheproperty,amexduelvetyc tmawith Ikeneedcontrectorstoconstmct
the project(Sec.7044,Business end Profalona esCode:The Contractors License law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who Wilds or knprov'ee thereon,and who contracts for such projects
Min a contwcron(s)licensed pursuant to Me Contractors License law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B 8 P.C.for MIs realm
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of penury one of Me following declaration: /
-11 he"and will mall a Cenlflcate of Consent to sell-Insure for Worker's Compensation, Building as provloed for by Section 3700 of the Labor Code,for the performance of the work for which this n•
permit Is lesuetl. �_-� —s.sa.) Seismic r O
have end will mal Performance
rmancWorker's Compensation Insurance.hthis as repulsedel Seddon 3700 of (f.! ` ` 'Ft' Jy O
Ihe�Wr Cora,for nc performance o1 the nworkumber
for which Mle permit Is Issued.MY Workers Totall 7.
Compensation Insurance earner and Policy number afro`
CarnerAM60-`4•AN PfOVIG11 IOr1 Ppucy No,15e)P_40Z_t,4G-7bG PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FRCM WORKERS'
COMPENSATION INSURANCE N.CL]
(TMs section neer Trot be completed If the permit is for one hundred dollars(5 100)or lees.)
I certify That In the performance of Me work for which MIs permit is Must,I shall rot employ .
any person In any manner so as to become subject to the Workers'ConryensatIon Laws of Cell- All roots:shall be inspected prior to any roofing material:being
forme. installed. If a roof Is installed without first obtaining an
oats Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: 1f,after making this Cerglkate of Exomptbn,you should beano Applicant understands and will comply with all non pint
subject to Me Workers'Compensation pnodalons of the Labor Code,you nwst tonhwlth campy PP P Y P
with such proAskxs or this permit Matta deal reei sours ulations.
I certify,Met I have rear MIs application and state that the above Information is correct.I agree
to comply with all dry and county ordlnsncas and state laws tell to Wilding construction,and Allr f v ng ot
-Ar better.
hereby authorwam
ize representati of this city to enter upon Me abentloned property for In.
spection purposes.
(We)agree to save.Indemnify'and keep harmless Me City of Cupertino egams,liabilities, . f C'I
judgments,tests and expenses which may In any Way accrue against said City In wmsequermca
ot the granting of this permit. SIGNATURE OF 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY