R-6377 APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R- 6377
INSPECTION DIVISION PERMIT EXPIRA 1 N
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS /�/I /)
2-2-S �. / Ne ��AIf} hIV C1S)6 ) RESIDENTIALV/COMMERCIAL OTHER
OWNER'S / HAZARDOUS FIRE AREA
hYES ❑ B yes-I understand Ihat a Class A
NAME_ N1 - P-6/.1 A P_ root assembly B required.
I NO Inual I.C.B.O.1
ADDRESS S A EXISTING ROOF COVERING
PHONE OIO 3 — -I NUMBER OF EXISTING COVERINGS �--
CONTRACTOR'S -
NAME I�YMhwMCa/Wr� f�(YJTIk)(, & INC, TO BE REMOVED 1- TO BE RETAINED
ADDRESS ^ TYPE OF ROOF COVERING
CITY&ZIP-�Z-C1 Z L l n3C.OL rJ AyE 5 1 9 S12.S EXISTING _
PHONE 408 — L{4'B — G9 BUILT-UP ROOF El
NUMBER LICENSE
SS`"( -36 GKP 3/3 1 IQ� ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION -
I hereby affirm that I em licensed under provslons of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business entl Profeselome Code,entl my Ilcerue is In full force and .
effect WOOD SHINGLES
License Class�� Llc.Number _ ❑ . .
e� O OTHER(SPECK ❑
Data I- �9 Contrectw
OWNER-BUILDE CLARAnON PROPOSED
hereby ,Buirm that em exempt from the Any
city
orUcerlcoup Law for the Wowing a reason. '
(Sec.7031.5, ,Improve
and Proleeelonp Aoy dry or county which requires a uir s t to
- caslnot,atter,Improve,demolish, n d statement
any ntruqure,prior to tie Issuance,also reproves the BUILT-UP ROOF
tIts Capplicant for such permit to file a sigma r P(commencing
co m that he s licensed Soio pursuant to the provolone
of the ss an Pro Liberal ssions Lew(Chapter h is exempt
t with therefrom
"7000)of Division 3 of the
exi,mees entl violation
Cade)or that he is exempt therefrom erg the beefs for the alleged antto ASPHALT SHINGLES CQl_OTe�
exemption.Any ltyofh t onel Sec tion 7031boyany ep$l ).bra permit eutyecte the applicant to
a dull penalty of hot more than Ove hundred tlallero(Ss001.)'.
❑1,as owner of the prof or Try employees with"gas es their sole compensation,will do WOOD SHAKES ❑
the work,entl Ne si ucture is not intended or offered for sale(Sec.70,14,Business entl Form.
eons Code: The Cantractora Llcarue Law does not apply to an owe clearly who builds or WOOD SHINGLES ❑ PResIDeNT1fN
Improves thereon,arb wile do such work hlmxtl or ihrouph lr m rm betl Net
such Improvements are not Intended or offend lar eels.If,ho ,r WIIdl mend
Iv sold within one year of completion,the owner-bu]Ids will have enol - et OTHER(SPECIFY) ❑'
not bulb or Improve for purpose of sob.). -
❑1,as owner of the property,em exckahely con0achrg with coniradore rst
Me project(Sec.7044,Business end Proleeelane Code:The radore,lkense Lew tloee PROVIDE LC.B.O.REPORT NO.
apply to an owner of property who Wilds or lmproee thereon, whocanttecteloguohprojecut
with a contractor(s)licensed Wrsuent to the Contractors L alaw. r V J P ROVIDE MFG R. INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P:C.for this
Owner PPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARAT
I hereby affirm under penelry,of perjury one of the following dodTratbn: /-
❑I he"and will maintain a Certebete of Consent to saff-Insure for Workers Com Buildingh r
as provided for by Section 3700 of the Labor Code,for the performance of the work lar which 7
permll Is Issued. 1 O
❑Ihaveand will the maintain performance
eCompensation Insurance,asrequiredIs Isbysection37000l (v�(C., Seismic /�
the Leber Cade,for the performance of the work for wh{ch this permtt le issued.Nh Worker's t ! O
Compensation Insurance carrier and Policy number are: - p � Total
Carrier STiLTP FUAA0 Pgldy Nle, ZES 1 3Z 19? PERMIT AUTHORIZATION DATE
CEWIRCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NQEI '
(This section need rot be completed If the permit is for one hundred dollare($100)or lose.) ��Q
I certify that In Ne performance of the work for which this permit Is Issuetl.I all rot employ
any person in any mummer w as to become subject to Ne Worke s'Compemsef on Lawn of Cell. All roofs shall be inspected prior to any roofing material being
lorrde. installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non Olnl
subject to the Workers'Compena itbn provisions of the Labor Code,you must forthwith comply pP P Y P
with such provisions or this peml sheRbe deemed rawokad. Source Ulation S.
I campy,that I have react this apf lbatbq and state that the above Inlormetlon Is correct.I agree
to campy with all dry and county artllnarwes and state laws relatlnp to iwlWlrg constructor,and All f f VeringS 10 b CI Or ballet.
hereby authorize representatives of this dry to enter upon the ebale-mentioned properly for In-
spection purpoal
(We)agree to save,Indemnity the entl keep harmless City of Cupertino against Ilablktlen, - /
Judgments,poets and expenses which may In any way accrue against said Gty,In consequence '
_ of me granting of this permit. SPNATURE OF APPLICANT DATE
S' PRE-INSPECTION: PLYWOOD: X IN-PROGRESS: - x
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL: X
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY