R-5874 APPLICATION FOR- CITY OF CUPERTINO NUMBER R' 58
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 7T7-3M PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN ISO DAYS OF PERMIT ISSUANCE OR
1130 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL - COMMERCIAL OTHER
OWNER'S _j _j HAZARDOUS RRE AREA
i
' /l 1 VES L7 N yes—I understand that a Clens A '
NAME y V P r-tA' \ _AA)SY r r ll 1 w) roof assembly Is required.
(� NO �, Intel I.C.B.O.;1
ADDRESS 3 • OC1 S +. EXISTING ROOF COVERING
PHONE R'S S O NUMBER OF EXISTING COVERINGS /
CONTRACTO / 2
NAME Old C.4' f l l TO BE REMOVED y' TO BE RETAINED.
ADDRESS Ij TYPE OF ROOF COVERING
CITY sZIP ` -,S67_ 111
! EXISTING
PHONE - Y0 p -r�7 b7_ ( 11. ' BUILT-UP-ROOF El '
NUMBER LICENSE 6 Z ( 3 I ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm met I an,licensed under provlslons of Director 8(commencing with Section WOOD SHAKES
7000)of Divblon 3 of the Business end Professions Code,and my license is In lull force and
ene
L,� / �^ WOOD SHINGLES 11
License Claes Uc.Number h C—
oote y'30 - Cl t - Contractor O�� �IA�J-I--f-u OTHER(SPECIFY) p /,�
OWNER-BUILDER DECI-IRATION PROPOSED 01?I hereby affirm that I em exempt from the Contractors Ucenaa Lew for the following reason. /1e J ss0
(Sec.7031.5,Business end Professions Code: Any city or county which requires a permit to
construct,after,lmpro+ ,demolleh,or repair any structure,prior to its lseuance,aUo requl he BUILT-UP ROOFC/J-y
epplfcent for such permit to tae a signed statement that he b licensed pursuant to the pioK
of the Contradora License Lew(Chapter g(commencinp wlth Section 70(0)of Dly slon 3 f
• Business and Protein Code)or that he Is exempt therefrom and the basis for the aASPHALT SHINGLES
e dvll penalty of not morefthan IHe hctlon undre31.5 d dollars applicant
SI Gnll)br a permit subjects the spell (J
❑I,as owner of the property,or my employees with wages as their sole compensation, WOOD SHAKES ❑
raw work,and the structure Is not Intended or offered for sale(Sec.7044,Buslneee and Pr e-
sons Code:The Contractors I-centre Lew ckm not apply to en owner of property wfro 00 SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,W
such Improvements era not Intended or offered for sale.If,however,the bulldIn0 or Improae
i
is sok within one year of compladw,the owner-bulldx will have the burden of prWg that he did Q R(SPECIFY) [�
not bulk or Improve for purpose of sale.).
❑I,as owner of the property,em excius"ly contraw g with licensed ow,lactda to construct ,�i�_ 3S Z 3
Me project(Sec.7044,Bluenose and Professlors Code:The Contractors Llcenes Lew does not / IptOVIDE LC.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Comranors License Law. PROVIDE MFGR. INSTALLATION SPECS.El em exempt under Sac. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby aHlrm under penalty of Wury one of the following dedeatfon:
11 have and will maintain a Certillcate of Consent to self-Insure for Workers Compensation, Building
as prodtled for by Sectan 3700 of the Labor Cade,for the performance o1 the work for which this
Permit k Iesuetl.
I3fIs Issued,
will melnteln Workers Compensetlan Ineunce,reas required by Section 3700 of ���0— J $elsmlc
the Labor Code,for the performance of the work for which this permit Is saueE.My Workers
Compensaten Insurance canter and Policy number are: v Total
CarrkrL -Q/n �,_.�Sp.rawceo^IoyNo.La)V!-OZ995� PERMIT AUTHORIZATION DTE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(Chia section need not be completed It the permit Is for one hundred dollen($1 D0)or lees.)
I cartlfy that In the performance of the work for which this permit W Issued,I shell nW employ
any Person In any manner so as to become subject to the Workers'Compensadon Laws of Cell- All roofs s hal I bEr inspected prior to Any Tool 0 at aI DMg
fornla. installed. If a roof is inst31 ole aining an
Data tI"30-518" AWI' al/�!./(JIAJI-�i` inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,alter making H&Carlificate of Exemption,you ahouk biome
s Mmt to the Workers Compensation proMsions of the Labor Code,you must forthwith comply Applicant understands and will comply with all.non point
with such provglons or this permit$hall be deemed avoketl. Source regulations. - -
I earthy that I terve reed this epplice mon and state that the above Inlormetlon Is coned.)agree
Pal to comply with all city and county Paand water lam larelating to bulldIng conetrucaon,and All roof coverings to be class"C"or better.
hereby authadze representatives of this city to enter upon the alek a mwtloned property for In-
apenreeea.
Wagree magainst
(We 1p save,Indemnity and keep I hay way the City of Cupertiro ncon Ieque consequence
'
of Me a of and expenses which they In any way earue epeln$t veld City In coneaquenca SIGNATURE OF APPLICANT DATE
of the antirg of We Perritt.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: - BATTENS: FINAL:
INSP. O DAT �`_/� INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY