R-6321.9
OFFICE COPY
PERMIT R- 63 21
APPLICATION FOR CITY of CUPERTwo' NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
- WITHIN 100 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS - -
/�, {J pC\ /.
ZIb,¢ 0 A rZ�•
X
RESIDENTIAL ` COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
'SAO" RSV
YES ❑ It yes — I understand that a Class A
NAME
roof asserMty Is required.
NO 01 Initial I.C.B.O. K
CT'
EXISTING ROOF COVERING
ADDRESSb�4mr�A�-zCy
PHONE Z5Z' �T� J
NUMBER OFFXISTING COVERINGS I
CONTRACTOR'S
NAME I/L� AISS� N�'Yi Wr�T tit �n l.(/_ (NL •
TO BE REMOVED TO BE RETAINED
r
ADDRESSZZ°) Z �� aG�. a I`ivC gS' `i51ZS
cITY&ZIP
TYPE OF ROOF COVERING
EXISTING
I I
4 4?Q '6)641
PHONE
.BUILT-UP ROOF ❑
LICENSE
NUMBER. 5�✓-IT�G
ASPHALTSHINGL El
CONTRACTORS DECLARATION
1 hereby afflnn that I em licensed under pravlelons of Chapter 9 (commencing with Section
WOOD SHAKES a
7000) of Dlvieldn 3 of Me Buslmm and Professors Code, and my Ilceme Is In full force ark
,
effect.
WOOD SHINGLES�e.'f /
Uconm ClaesContractouc. Number
II qfi/�4 K.ErTnT;SAqL�MGtAI(,y
Oeta - r
OTHER (SPECIFY) 5/
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contructofe License Lew for the Idlowing reason.
PROPOSED
(Sec. 7031.5, Business and Prolemkns Cade: Any dry or county which requires a perm0 to
comtrucl, alter, improve, demoseh, or repair any structure, prior to He lseuence, also requires the
BUILT-UP ROOF ❑
applicant for such permit to file a signed statement Mat he h I B�oo�tthhe�
Me Contracus's License Law 9 Ion hbWviskn
of (Chapter (commencing with 7000 3 a
Dueness and Profeesiats Code) or that he Is exempt there) the844-,the all d
ASPHALT SHINGLES [®
exemption. Any violation of Section 7031.5 by any applicant for p� pe t pli o
e civil of most more Man five hurkred dollars ISSmI ):
penalty 1
' ❑I, the th
WOOD SHAKES ❑
as owner of property, or my emplayaes withwegee reql� b7n,.W�'
the work, and the structure b not Intended or offered for sale .70AM fiLiBliy
Blom Code: The Contractor's Licenso Lew does not apply to a nor o property who W aor
WOOD SHINGLES El
Improves thereon, eM who does Bush work himself or through own employees, provided that
such Improvements are not Intended or offered for sale. If, how mar, the Whiting or Improvement
Is soW within one year of completion, Me owner-Wllder will tfy WNen of proving that he did
OTHER (SPECIFY) Elnot
Wild or Improve for Wrpoee of sale.). 6y
❑ I, as owner of the property, am excluslroiy contracting wi
the protect sec. 7044, Business am Prolewlons Code: The Contractor's "me Lew does, not
PROVIDE I.C.B.O. REPORT NO.
appy, to an owner of property who sulfide, or snpoven thereon, and who connector for such projects
with a oxuremgs) ficansed pursuant to Me contractors License law.
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 am exempt untler Sec. ,B 6 P. C. for this reason
Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKERS COMPENSATION DECLARATION
/ �7 -
Building
I hereby affirm under Wnalty of perjury one of the following declaration:
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which be
Is Issued.
1 n
I
G %
5
permit
Ill �y -1�
L1y}}'h�
���
Seismic �O
II I have and will maintain Worker's Compensation Insurance, as required by Section 37W of
J.V
I I
the Labor Code, for the performence of Me work for which this Permit is Issued. My Workers
Compensation Insurance carrier and Polley number are:
Total
'Carder gTA-ag� GV1.)b Policy No. IN Z�j 5
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need mat be completed it Me permit Is for one hundred dollen ($100) or lase.)
I certify that in the pedormence of the work for whkh thio pennit Is house, 1 shell not empty
any person In any manner so as to become subject to the Workers' Compensatcn Laws of Cali
All roofs shall be inspected prior to any roofing material being
fornla.
installed. If.a roof is installed without first obtaining an
Date Applicant
inspection, Iagree to remove all new materials for Inspection.
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
Applicant understands and will comply with all non point
with such provisions or this permit shall deemed revoked.
SOUr r ulations:
1 certify that I have reed this eppiloation end nate Met Lha above Information Is comect. I agree
to comply with all city end county ordinances and state laws rnai to Wlldr construction,entl.
All 0 O)V8(Jn9 be lass"C"Orbefter. '
hereby autWdze representetives of this cty to enter upon the above-mentioned popery for In-
epedbn purposes.
(We) epee to save. Indemnity and keep hormions the Cly of Cupertino against Ihbiltlm,
SIGNATURE OF APPLICANT DATE
jmgmlents, caste and expenses "Ich may In anyway accrue against oak C ty In consequence
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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY