R-6489 APPLICATION FOR CITY OF CUPERTINO NUMBER �. 6489
.
INSPECTION DIVISION PERdITEXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS CF PERMIT ISSUANCE OR
- 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
-7q3 Cl- 61e 141v RESIDENTIAL,?!�__COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A.
NAME root assembly is required. -
NO ❑ Inal LC.B.O.Y
ADDRESS EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS Z
CONTRACTOR'S
NAME -t� I`af7 f CO• /(,: TO BE REMOVED ?' TO BE RETAINED
ADDRESSTYPE OF ROOF COVERING
S. 7
CITY&zlp& _f7.A, ' 5�,...i 54se �r��Z. EXISTING -
PHONE/ 1/O4 ZqZ - 76V q BUILT-UP ROOF
Litems
R (� T 7 Z ASPHALT SHINGLES ElNUMBE
LICENSED CONTRACTORS DECLARATION
hereby affirm that I em licensed under fess n, of e,am r a(commencing is In full
mSectionand WOOD SHAKES ❑
]000)of Division 3 of the Business entl Proleesfons Cade,end my license b In lull farce and
ansa. - WOOD SHINGLES ❑
donne Claes_ Lb.Number 9/`m f/77 Z_
Data�'�6 99 Conteactoret C4,0," (coo �r<-/D/ OTHER(SPECIFY) nn
OWNER-BUILDER DECLARATION «✓/ L]
I hereby affirm that I am exempt from the Contractors License Low for the following reqs PROPOSED D
(Sec.7031.5,Business and Pmfessone,Cade: Any city or county which requires a permit to
construct,eller,urprove,damotlsh,or repair any structure,prior to Its bauencealae requires the BUILT-UP ROOF F*R 16 1999
applicant for such permit to fie a aigned statement that he Is Iltenaee pursuant to the prwbions
of the Contractors Ucsnee Law(Chapter 6(commencing with Section]000)of Division 3 of the
Business and P,efesedna Code)or fuel he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑
memptlon.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of net more than five hundred dollars
❑L ae owner of the property,or my employees with wages as their Bola compensation,will do WOOD SHAKES By n
the work,and the structure Is not Intended or offered for sale(Sec.70 ,Business and Profes-
sfonsCode:The Contractors License Law does not apply to an owner ol.property who bulldsor WOOD SHINGLES
❑
Improves thereon,and who does such work himself or through his own employees,provided that
such Imprwements are not Intended or offered for eels.If,however,Me Wilding or Improvement
U sold witNn one year of completion,the avnter-builder will have Me burden of prmrg that he tlid OTHER SPECIFY
rot build a Improa for purpose of Bele.). ( ) ❑
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.70n4,Business and Professions Cade:The Contractors License Law does not PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who bullda or Improves thereon,and wW contracts for such projects
with acontretemps)nS pureuemto the Contraeeora License Law. PROVIDE MFGR. INSTALLATIONSPEC$.ND36/5—
❑I em exder Sec
attempt under . ,8 8 P.C.for this real
fens
owner Date
WORKER'S COMPENSATION DECLARATION APPL CATION DATE VALUATION PERMIT FEE
/
I hereby end under penalty of perjury one of the bitewing dura for Wo
❑ neva entl will maintain37 a ofGerifficareab of Consent to"if-insure for Workers C for a kation, BUlldln
asprovis is laMSectlon 3]00 of the Labor Code,for the perlormarxxt of Me wuM for which this 7/ �j 9 '7 Building
os
mit (� 1 1 Seismic
❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 of j�f✓T!�
the Labor Code,for the performance of the vrork for which MIs permit Is Ieeuetl.My Workale
rc
Compensation Ineurea carrierander end Polley numbs are Total
CanJAI -9—MINS /�7J�+ t� PolicyNo�Z�u79' p0 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C[]
(This section need net be completed It the permit Is for one hundred dollars($100)or bee.)
I certlry that In the performance of Me work for which this permit U Issued,I shall notem
any person In any manner sel as to become sublecf to the Workers'Compensation Laws of All roofs shall be inspected prior to any roofing material being
fomia. installed. If a roof is installed without first obtaining an
Date All inspection,l agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Cenelcate of Exemption,you should became Applicant understands and will tom with all non mint
subject to the Workers'Compensetlon provisions of the Labor Code,you must forthwith comply PP comply P
with such prodacrui or this permit shafte deemed revoked. sourceregulations.
1 certify that I have reed this application and elate that the above Information is correct.I agree
to comply with ell city and ryordlnarKee counand elate laws rotating to building construction,and All roof covergs class'C'or better.
hereby aultrorize representatives of this city to enter upon the above-mentioned property for in.
spectlon purposes. -
(We)agree to save,Indemnity and keep harmless Me City of Cupertim epainst liabilities,
Judgments,coots entl expenses which may In any way accrue against geld CIry In consequence
of MegreIn et this I. /-SIGNATURVOOFAPPLICANT DATE
• PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
ll 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