R-6095 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER V O
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS //Y•i •
180 DAYS FROM LAST CALLED INSPECTION./!i� N• Kms•-rC�loo� A-� '
(�J RESIDENTIAL COMMERCIAL OTHER
-
OWNERS /'7O� // 1 HAZARDOUS FIRE AREA
NAME , �ff� :l/&4rmI7 I�w VES ❑ H yes s I assembly
is andreq that. Class A
rml assembly rs raquiratl.
NO ❑ IraOal LC.B.O.%
ADDRESS ���G LT' �rrGdcbn �TvR EXISTING ROOF COVERING
L
NUMBER OF EXISTING COVERINGS
PHONE•
CONTRACTOR'S
NAME TO BE REMOVED TO BE RETAINED
- F 'S ( � [^�F�/ •
ADDRESS TYPE OF ROOF COVERING
CITYa7lP_G70� GY<(OG(t9 Kz. j. EXISTING
PHONE 7Z6- 3(/ti BUILT-UP ROOF El
LICENSE / / -
NUMBER �/ p ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
]000)of D affix 3 W the licensed
and Pro easkxu Code,
8(commendng with Section WOOD SHAKES ❑
my license is In full tome end
effect.
46WOOD SHINGLES
License Clew Lb.Number - � ❑
Date £ Contractor ICS COffl7 OTHER(SPECIFY) ❑
OWNER ILOER DECLARATION
I hereby affirm that I em exempt tram the Contractors License law for t4bllow1ng reason.
(Sec.7031 6,Business and Professions Cotle: Any city or county which requires e permit to
construct,alter,Improve,demolish,or repair any structure,pdorto its Issuance,as requires theJBUILT- PROOFapplicant for such permit to file a signed statement that he le Ibensed pursuant tic the provlabneof the Contromun's License Law(Chaptr g(common r with Section 7000101DINsBusiness end Proleselons Code)or that he Is exempt iho%rcen and the biT(r?p�6 IOreLT SHINGLE$axemPpen.Artyf not mn of Satlon hundr byanyeppllnt laxapemnit aubl}rIe t e epplcent Ibe dull Penalty of not more than Hue hundred dollen(5600).): I I1,as owner of tha property,or my employees with wages an their ebb q� aeric IA doSHAKES ❑the work,antl the Mrpctura la rout Intends or offers for sale(Sec.7004, es en tee-
sbrn Code:The Contractsrs License Law does not empty to en owner ofp 8orSHINGLES
Improves theran,and wfa dbas such work himself or through his own employees,pro+l ❑
such Imprmemems are not InterMe or offered for sale.If,however,Hre bWiding or Improvement
Is said w thin we year of completion,the owner-0ullder will have me burden of prming thel he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
1,ao owner of the property,em exdusivefy,cbn,rectlrg with licensed contractors to construct '
the prefect(Sec.7044,Business end Professions Cole:The Contractors Lkenee Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds o Ynprovas thereon,aril who contracts for such prefects
with a contrac,ods)licensed pursuant o the Contractors Ucense Law. PROVIDE MFGR.INSTALLATION SPECS..
❑1 are exempt under Sec. ,S 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of Perjury one of the following declaration:
❑1 have and will maintain a CortiHcete of Consent to self-Insure for Worker's Compensation, 27
permit
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this g/�'f I ( Building
permit Is Issued. 1 •/
rg I hove sed will maintain workers ConpensatJon Insurance,ac required by Section 3700 of - Seismic
me Labor Code,for the performance Of Me work for which this barren is Issued.My Workers Total $7, s7b-'
Compeneallm Ineurence carrLier antl Policy number are '
Carder Polky No. Z-�-9— PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C43
(This sactlon need not be complete H the permit Is for one hundred dollars($100)or Nese.)
I certhy met In the performance of the work for which this permit is Issued,I shell not employ
any,person in any manner so as to become subject to the Workers'Companeeon Laws of Call- All roofs shall be inspected prior to any roofing material being
10""B installed. It a roof is installed without first obtaining an
Date 1 f P Amwl a - inspection,I agree to remove all new materials for inspection.
NOTICE APPLICANT: If,after making this C&AIcator of Exemption,you should become Applicant understands and will comply with all non Dint
ii to the Workers'Compensation provisions of Labor Code,you roust formwlth comply PP P Y P
with auch provlelons or this permit"be deemed revoked. source regulations.
I certify that I have read rims apphcetbn end!state that the above Information is contact.I agree
to rampfy with all city and county ordinances and state laws relating to building constructed,end All roof coverings to be class"C'or better.
hereby authorize refxeeenthtivas of this city to enter upon the above-menlloned property for In-
spect purposes.
(Wed
spree to seve,IMemnlfy ee keep harmless the Cly of CryerHro agel^et IleblllHae, v'I
Judgments,costs and expenses which may In any way accrue against cold CIry In consequence
of the granung of mm pe"t. SIGNA RE'OF APPLICANT 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 ACCESSTO.ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY