R-6491•
PERMIT
6491
APPLICATION FOR CITY OF CUPERTINO NUMBER •R_
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 7%7-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
- WITHIN 100 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
�'/;Ep�
/0/;7//7C
('/
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RESIDENTIAL COMMERCIAL OTHER
OWNER'S��j^y.�
HAZARDOUS FIRE AREA
-
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YES ❑ II yes Chad a Class A '
NAME /,/� /'t.Ts ' 7 fi��.4 / S
s mbly is req
/cool assembly Is required.
NO � LT. India! LC.B.O. Y
_
EXISTING ROOF COVERING
PHONE(�vQ 7/ /YO ro/
NUMBER OF EXISTING COVERINGS
TO BE REMOVED �TO BE RETAINED
CONTRACTOR'S /
'%
/- ��9 As' C Z
- l.. Q l
NAME T
�
ADDRESS�. . 3s- 5 �3 /%O
TYPE OF ROOF COVERING
CITY BZIP �
EXISTING .
7 —7J �x
63 3 / / (�'��G
PHONE / /
BUILT-UP ROOF ❑
LICENSE nZ C2
NUMBER // 77
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter B (cormsndn g with Section
WOOD SHAKES
7000) of Divlebn 3 of the Business and Professions Cade, and my Ikanee Is In full force and
effect' /' %
C— ��
WOOD SHINGLES
Vz,
License Claes Lid. Number - <
�o
OTHER 1SPECIFY)__
Date Contractor
ON from th ILDERD LLicensN
hereby that am exempt from the ore Lew for the following reason.
�PRO i /L ,
� LT—
, Bu or roue to
(Sec. 7031.5, Business and Profeolish, sbne Code: Arty city a county which rea
e: Any
1 l
on d sul any m that re, prior to Its issuance, pursuant algia requires gra
am quires
construct, alter, Improve, demolish, a signed
of permsto III% aChapt eaamemthat he Nconsetlp pro
BUILT-�LJJr((??I ROOF
APR 2 0 1999
000)o Dthe
the Contractors i of
of the Conirid Pre Llsions Lew (Chapter 0 Is exa (command with Section 7000) of for the 3 0l dre
.A Professions Code) or that he le exempt Merelr and the Beals for the alleged
IIr'
ASPHA.�j SHINGLES
exampse
axempparr. Anyviolationo of
of Section 7031.6 by any eppllcent for a permit subjects the eppllcent to
a
t M
e civil panwry not mom men five hundred donee
the
WOOD SNi�KES ❑
with wag.):
a property, or ertployeee withor"a as their We compensation,will
❑1,k,ownerof
h Intended for Busineee Proles-
the work, and the structure rot to or offered Bele (Sec. ]044, end s-
t or
ekes Code: The Contractors es Bud Lewd not appy to en owner of property who provided
Improves thereon, and w1w dose etc self or through hla awn employees, prwltletl that
WOOD SHINGLES ❑ �'/� c /�
Sj
such Improvements ere not Into d to�rr !Ia. If, however, the building or imprarement
Is sold within one yaer olcomplel a r,argader will have the burden of proving that he did
/� r
OTHER (SPECIFY)
not build or Improve for purpose sal '
❑I,eeowneroltheproperry,eme usiverycontractiwith licensed contractors to construct
the (Sec. 7044, Business and rofeeelons Coda: The Contractcre License Lew dose not
'(
PROVIDE I.C.B.O. REPORT NO.
project
apply to an owner of property who builds or improve%maroon, and who contracts for such projects
with a contmooga) Ilcensed pursuant to the Contrndore License law.
_
PROVIDE MFGR: INSTALLATION SPECS.
❑ 1 am exempt under Sec. ,B 6 P. C. for this reason
Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
' WORKER'S COMPENSATION DECLARATION
�/ �
I he" affirm under penalty of psdury one of the IodoMng oedanation:
❑ 1 have and will maintain a Cantdfcete of Consent to sell -Insure for worker's Compensation,
BulldlniL—
as provided for by Section 3700 of the Labor Code, for the performance of the work for which rale
bermft ed.
('0�
and will maintain Workers Compeneetlon Insurance, required by Section 3700
9
Seismic
ae of
the Leben Coda, for the parfomnance of the work for which this pemYt b sawed. My Workers
/
CS/ O O
'Campensatlon �Irsumnce caller a Polley numJber ere:
Total
PERMITAUTHORIZATION
DATE
Carrier�S %P uyQ Porky No. Z�rS=/%9'/3/
CERTIFICATE OF EXEMPTION FROM WORKERS'
p
LOQ, p•
COMPENSATION INSURANCE NCO
(This section need not be completed If the permit Is for we hundred! doll ($100) or lees.)
I certify met In me performance of the work for which this permit D Issued, I shell not employ
any person In eny mems, sa as o beco o subject to the workers' Compensation lava of call- �
All roofs shall be inspected prior to any roofing material being
ta`nla.
installed. If a roof is installed without first obtaining an
Date
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: I her maklag this Cemliaate of Exemption, you should became
eubled to me Waken' Comp nsatfon proviebne al the Labor Code, you must lorlhwim comply
Applicant understands end will comply with all non point
with such provisions or this permit shady a deemed revoked.
source regulations.
I certlry mat I have read this application and state that me abate Information to corred.I agree
to comply with all city and county aNnences and state leve relating to budding construction. and
All roof Coverings to be Class Or better.
hereby authorize represenativas of this city to ether upon the ebovemrentloned property for In-
spection purposes.
(We) agree to save, Indemnity, and keep harmleae the City of Cupertlno against Ilabdlllee,
Judgments,costs
f pemit� which may In any way tot" egalnet said City In consequence
OF APPLICANT,,, --TE
seems,
t�
YNATURE
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