R-6432ie
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OFFICE COPY
PERMIT
R- 6432
APPLICATION FOR CITY of CUPERTINO NUMBER .
INSPECTION DIVISION PERM IT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK is NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1W DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
7
RESIDENTIAL COMMERCIAL OTHER
OWNER'S 'A -
HAZARDOUS FIRE AREA
YES ❑ If yes - I understand that a Clens A
NAME fj «<---..v
roof assembly Is reclulrad.
NO o Idbal I.C.B.O. k
/
EXISTING ROOF COVERING
�� L �v�QLy/ti
ADDRESS % /!)
NUMBER OF EXISTING COVERINGS
PHONE
'
CONTRACTOR'S
NAME f G/�
TO BE REMOVED TO BE RETAINED
ADDRESS^Z /��� /� A��
TYPE OF ROOF CO
Cm a ZIP ��LUC�J [�! /*
EXISTING
//�L
�,�
/�/
PHONE_ ��8 y z
BUILT-UP ROOF ❑
ASPHALT SHINGLES ❑ tel.
WOOD SHAKES
LICENSE
NUMBER lJ
LICENSED CONTRACTORS DECIARATION
I hereby affirm that I am licennol trader Provisions of Chapter 9 (commencing with Section
]000) of DMslon 3 of me But lneas and Professions Cade, entl manse Ie In full force end
effect.
'_
Dcenea Close � - � � Lk. Number
WOOD SHINGLES ❑
�%^ 9 g contractor
OTHER (SPECIFY) /fi�'rAL
'
DVJNER-BUILDER D CLA ON
Lor
I hereby affirm that I am exempt from the Conimdor' nse the following reason.
PROPOSED
(Sec. 7031.5, Business and Professions Cape: Any c r county which repulse a permit to
conal ruct, after, Improve, tlemollsh, or repair any st e, prior to Its Issuance, also requires the
BUILT-UP ROOF ❑
appl cent for such permit to file a signed statement that he Is Ilcensetl pursuant to the prwlslons
of the Contractor's Lkenae Lew (Chapter B (commendrg with Section ]000) of DMelon 3 of the
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Busness and Professions Cade) or that he Is exempt therefrom and the basis for me alleged
ASPHALT SHINGLES ❑
exemption. Any violation of Section 7031.5 by any applicant for a permit subjopis the applicant to
e cMl penalty of not more man five hundred dollars ($500).):
owrpr Nair do
WOOD SHAKES ❑
❑I, e9 of the property, or my employees with Papas as edeco will
the work, entl the structure Is not Intended or offered for sale (Sec. ]044, Bus en
Bions Code: The Conlnactoes License Lew does not apply to en owner of pr ho bull
HINGLES ❑
Improve thereon, and who does such work Nnxeeti or through his own emL ld
�t/kl
such Improvements are rot Intended or offered for sale. H, however, the Ww ant
Is wltl within one year of completion, me owner -0 lcor will have the burdenet he did
0 (SPECIFY) ❑
rot Whit or Improve br purpose of sale.). 1, with licensed
the
719998
es owner of property, am exdu I contracthq c
the pmjrol (Sec. ]044, Business and Protesedns Code: The Correctorsdoes..apply
E I.C.B.O. REPORT NO.
to an cwher of property who DWlds or improves thereon, and who contprojectswfth
a contrector(s) licensed pursuant to me Contractors License Lew.PR
E MFGR. INSTALLATION SPECS.
1 em exempt under Sec. ,B reason
AP ON DATE VALUATION PERMIT FEE
Owner Date
WORKER'S COMPENSATION DECIARATION
It
I hereby affirm under penalty of perjury one of the following declaration:
I have and will maintain a CarWkate of consent to self -insure for Worker's Compensation,
C]3
Building 7. o�
as provldetl for by Section 3700 of the Labor Code, for the Performance of the work for which this
per colt Is Issued.
g/j g/�
9�/}J5
Seismic ?o
❑ have and will Worker's Compensation Insurance, as rm by Section of
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(l
,
the peln
it 1. I Worker's
the Labor Coda, far the annenco of the work for which rola permit Ie Iseuotl. My Worker's
/ �/'
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r 33 7,9
Campenscam end/Pal number ere:
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Tote ^^
Carrier—o=�� v� Poucy No. �� T "
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
L�
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COMPENSATION INSURANCE N.C{]
(This section need not be completed If the permit Is for oro hundred!dollars ($1 W) or bv.)
1 certity met In me perWrasece of me work lar which this permit Is Issued, 1 shall rpt employ
any person In any manner w as to become subject to the Workers' Compensation Lowe of Ca1F
All roofs shall be inspected prior to any roofing material being
fornix.
installed. If a roof is installed without first obtaining an
Date Applicant
inspe ion, I agree to remove all new materials for inspection.
NOTICE TO APPUCANT: 11, after makkq dds Certificate of Exemption, you shoud become
'
A lira t understands and will comply with all non point
subject to the WoM Comps we Pro askors of the Lobar Cade, you moat forthwith comply
with such provisions or this permit shell W deemed revoked.
ource gulations. -
I certify met I have read this application and state that the above Incarnation is correct. I agree
to coney with all city and county odmances and state laws relating to building construclbn,entl
All Co rin sto be ss" "Or better.
hereby authorize representatives of ills city to enter upon the ebove-mentionetl property tar N-
epeWen purpeeoe.
�
(We) agrees nave, and keep he the qty Ci agay
Ct Iequelablifi
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wayhow
ai In con
consequence judpmama, coats entl expenses which they In arty way accrue against mltl Clry In coneequenco
expenses mid
SIGNAT R OF AP ANT DATE
of the grentirq of Nis permft.
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 PROV ED FOR INSPECTION
OFFICE COPY