R-6241 PERMIT R_ 6241
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)7T7-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/08!
RESIDENTIAL COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA
jun,, yn YES ❑ 1 yes—I understand that a Class A
NAME ^^^^ yId assembly is required.
NO Mal LC.B.O.tl
ADDRESS EXISTING ROOF COVERING
PHONE SSS 2 NUMBER OF EXISTING COVERINGS z'
CONTRACTOR'
S 19 P TO BE REMOVED Z" TO BE RETAINED '
NAME A
ADDRESSI-- ----TY-2E IN
CITYazIP/��(J /Q eJ�Y� �L50 2,—':S -6 t�
PHONE< •—, `" 2 _• y L
IUIL UP�ROQF1999.. D ❑
LICENSE .32-5131 SPHALT SHINGLES
NUMBER
LICENSED CONTRACTORS DECLARATION '
I hereby efHrrn met I am licensed under provisions of Chapter B(commencing with Section 000.SHAKES ❑
]WO)of DNIWon 3 0l the Business and Professions Cade,and my license is In full lone and
g
eet' n WOOD SHINGLES
LIcenaa Cl G39 Uc.Number
Date j4 f 4 4 Connector OTHER(SPECIFY) ❑ CCC///
ONNER-BUILDER OECL License
PROPOSED
I hereby ,Bu in that I am exempt from Ma Convectors or coup Law for the requires
following mesas.
(Sec.]031.5.Business and demolish,
or rM r de:any Any dry on oounry which re,also requires rmfl M
applicant,or er,su Improve,demola signed taement thate,pcontous ed pursuant toilMe BUILT-UP ROOF ❑
of me oforsuch Permit to asignedr 9(comm that he Is Incensed pursuant Sof the -
of Ma Cs,and tors License Lew(Chapter B(commencing with ef Sac Mon]000)al Oki Me 3 of the
Buempno entl Pro nation f Cotle)w that he a exempt ant for
and the basis Sts a the elated ASPHALT SHINGLES Tf/
exemption.Artyf not one t Secikxr hundred
byal�applicantforapermft eugeca the applicant to
e dull,anally o not more than Ilya huntlred yetis (h wag): �G o S a
❑ick. ownerolthe property,not
tended employeeswithfor Isastheir c.70oa compensation,will do WOOD SHAKES ❑
dro work,and the structure Is not Intentled or offered for sale(Sec.]044,Business entl Profae.
elol Code: The Contractors License law does not apply to an owner of property who builds,or WOOD SHINGLES
Improvers thereon,antl who deals such work himsalf or through his own employees,provided Thal ❑
such Improvements are not Intended or offered M sect.If,however,Me building w Improvement
is sold wiMln one year of campatlon,the ownenbulleer will have the burden of proving that he old OTHER(SPECIFY) ❑
not build or Improve for puWe of sale.).
❑I,as owner of the property,em exchish ely contracting with licensed xmmac om to construct
the project(Sec.7044,Business and Profession,Code:The Convectors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or lmpmvee thereon,and who contracts for such projects ,
with a cantracmge)licensed pursuant to the Convector's License Lew. r PROVIDE MFGR.INSTALLATION SPECS.
C]I em exempt under Sec. ,B&P C.for this meson
Omer Dale
WORKER'S COMPENSATION DECLARATION APPLICATION DATE -VALUATION PERMIT FEE
I hereby affirm under penalty of Perjury one of the following declaration. I /�
❑ have and will melnteln a of the Lab of Consent to eee4nsum for Workers Compensation,axwhicthe /� `� Od Building
as,provMatl lard will marman a Cerfi Labor Code, nt to el!A r r for of the work fh Ma / `/ Q' /.�
pa:rryjfslaavad' Seismic T
r'� hove entl will maintain Worker's Compensation Insumnes,as required by Section 3]W of
the ebur Coda,br iha pedormence of the work for which this penny Is Issued.My Workers
ansetlan Ins nc carrier entl Policy number ere: .�p�
Total
Cerner policy N.24P �8�� �6 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' --
COMPENSATION INSURANCEN.CQ
I cantly
(This section need not be compared II the Permit Is for one hunomtl colors($100)or less.) �� 2de
that In Oro performance of Me work far which this permit Is Issued,I shell not employ ,
any person In any manner so as to become Subject to the Workers'Compensettlon Lewis of Cell- All roofs shall be Inspected prior t0 any roofing material being
fornia. a[ installed. If a roof is installed without first obtaining an
Dem IF Applicant - • Inspection,I agree to remove all new materials for inspection.
Nal (CANT: If,after making this Gertificatehf Exempvon,you should became applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of Me Labor Cads,you must brMwilh comply
wiM such provisions or this pem0 shelP,be deemed!ril source regulations. _
I sanity that l have read me epplbaHon and slate Mat the above information is conact.I agree
to comply will all dry and county ordinances ane elate awe relating to building construction,eM All roof cpverin to be cla s or better. /
hereby purdzanrepresenativaS of Mle dry to enter upon the above-mentloned property tar In- —Y!J/SJ• c ' /�LO
(We)agree to save,Indemnity arel keep harmless the City of Cupertirw egabst liabilities, . i
jungmens,costa entl expenses which may In any way accrue against weld Ciry In coneaquanca
M
n gents,
of this permit. SIGNATURE OFAPPLICANT OATE
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'