R-6412 PERMIT
APPLICATION FOR CITY OF CUPERTINO
NU BER Rss 6412 .
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228_ , 'PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
1130 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
Boa LLAL� _
RESIDENTIAL COMMERCIAL OTHER
OWNER'SHAZARDOUS FIRE AREA
,{/� VES LI If yes—I understand that a Class A
NAME - /1,Q.d17'Litil/1-Q,PM� mof assembly Is required.
NO ❑ InNaI LQB.O.q
ADDRESS -5 EXISTING ROOF COVERING
PHONE 9-5 — 3 2-- NUMBER OF EXISTING COVERINGS
CONTFIACTOR'S t
S TO BE REMOVED TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
,,�a C EXISTING
PHONE � (rip'2-�FS� L3 BUILT-UP ROOF ❑
LICENSE
NUMBER 2S/ - ASPHALT SHINGLES
LICENSED CONTRACTORS DECIARATION
I hereby affirm Chet I em licensed under ph lelone of Chapter 9(commencing with Seclfon WOOD SHAKES ❑
7000)of Diviaon 3 of the Business and Prclasslons Code,ark my license is In full force and
effect. WOOD SHINGLES ❑
License Clava Llc.Number / /
61 ❑
Date Contrader OTHER(SPECIFY)
OWNER-BUILDERDECLARATIOl
torsUcome PROPOSED T
hereby ,Bu that em exempt Imes the Coca: Any city or coup Law to ma follouires a reason.
(Sec.7ct,aft ,Imp ove sod Proteolish,or rep itanArty dry or county waut requires a permit to
construct,ensu,Improve,demolish,or repeat any structure,he prior to Its lesuarroe,also the
the •BUILT-UP ROOF
eppl{cant for each permit to Elle a signed statement that he U licensed pursuant to the provlelons
Of the Cantredore Ucer se Law(Chapter 9(commencing with Sol 71XW)of Division 3 of Me �
• Business and Professions Code)or that he b exempt therefrom end the heals for the alleged ASPHALT SHINGLES �/7 ( �
exemption.Any violation of Section 7031.5 by any applicant for a permit suelacts the applicant to /
e co"penalty of not more than live hundred dollars($500).):
C]1,as owner of the properly,or my employees with wages es their sole compenutbn,will do WOOD SHAKES ❑
Me work,end the structure Is not Intended Or offered for sale(Sec.7044,Business and Proles-
edrs Code:The Contractors License Law does not apply to an owner of property who It llda or WOOD SHINGLES
Impr.thereon,and who does such work himself or through his own employees,provdetl that ❑
such improvsmenta are not Intended or offered for sale.It,however,the building or Improvement
Is sold within one year of completion,the owner-budder will haoe me burden of prodng mat he dm OTHER(SPECIFY) ❑
not Wid or Improve for purpose of mW).
[:11.es owner of the property,em excaus"Ill contracting with licensed contractors to construct
Me project(Sec.7044,Business and Professions Code:The Conbedoes License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who b ullds w Improvae thereon,and who coniracls for such projects
with a contrectorts)licensed pursuant to me Contractors License law. PROVIDE MFGR. INSTALLATION SPECS.
❑I em exempt under Sec. ,B 6 P.C.for this reason
Owner Dale APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarlbn:
11 have and will maintain a Certificate of Consent to eeff-Ira re for Workers Compensation, D`a Building
rm
as provded for by Section 3700 of the Labor Code,for the performance of the work fer which this {�/
pele Iesued. / 9 / /d 0 Seismic j0
I have entl will maintain Workers Cempersatlan Insurarroa,es required by Section 3700 of ` �/ /
thgGbo,Code,for the performance of the work for which We permit is Issued.My Workers
mpernetlon Irvuranc Mer
and Paltry number am: �s� �j Total f1LtLL
Canter _ � Policy No.�`ss �y��P PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N,C.I] o
(This section need not be completed It the permit Is for one hundred dollars($100)or lase.) �_ T
I certify that In the pedormal of the work for which this Permit Is Issued I shall not am lay
any person In any mummer so m to be me subject to me Workere'CompensaLaws wa of Cath All roofs shall be inspected prior to any roofing material being
fwnia. �Q installed. If a roof is installed without.first obtaining an
Date b N4 Applicant inspection,I agree to remove all new materials for inspection.
NOTICE
Ela wokere� r Iran« rowekxwa�� O�empou must
anona become Applicant understands and will comply with all non point
with Corry p you must forthMm comply .
with each prmlelme or role permit shall be deernetl rewketl. SOUfCe fagUatlOftS.
I cerdty that I have read this application and state that the above Information Is coned I agree
to comply with all city and county Ordinances and state laws relating to building construction,and All roof cov jjjiii111i��C�fI���to be cl as
. or better.
.hereby authorize lativea reprasenof this city to enter upon the above-mentioned property for In- ��
spedbnutil aa.
(We)agree to save,Indemnity and keep harmless me Clay of Cupertino agamit Iist,li ties,
judgments,costa and a expenses which may In any way aacroagainst sad City In consequence SIGNATURE APPLICANT DAT/
. of the granting 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