R-6270 PERMIT R_ 6270
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
r 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
{
RESIDENTIAL / COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME �k �"� f�s. YES ❑ N yes—I understand III a Clew A
root assembly Is required.
NO ❑ INtW I.C.B.O.Y
ADDRESS— ��Y5�3-- '•-�L � ' - EXISTING ROOF COVERING
PHONE ' 777 NUMBER OF,EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED / TO BE RETAINED
NAME
ADDRESS 70� , IS,
G, Lo f jos yv�J o 32 TYPE OF ROOF COVERING
CITY 8 ZIP
>EXISTING �
PHONE -`' / Q?'I��7 7��1/ BUILT-UP ROOF ❑
LICENSE
NUMBER 727V ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed muter provlelons of Chapter 9.(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business mrd Professions Coce,ano my license is In full force and
effaat' ,1/- WOOD SHINGLES
Lkrense Owes Uc.Numoer 7z7,f W - a
.Data 9' 30 '�� Contractor 'e G OTHER(SPECIFY) ❑
OWNER BUILD3or's DECLARATION PROPOSED
hereby affirm that em exempt from the Co or'e cen�i;t'awfor8re foil Ing.reesm. /w I -
(Sec.7031.5,Buelnaee and Professions CL"frals
dry or county,which regdlres a permit to e'GJ`//
mrutrud,seer,Improve,tlemolLah,w rep Irtire,ptlIgo lbb fuanoff,ileo rectifies ma BUILT-UP ROOF
applicant for such permit to Ne a signed Slat he b Ircensed°pumuenl b the provision:
of the Contractors License Iaw(Chapter B n wHh Saothl 7000)of Divblon 3 of the
Business and Professions Code)or that ht basis for the alleged - ASPHALT SHINGLES
exemption.Arty vlalauon of Section 7031.5 ��I�uW99l�applicant to
a dvll penalty of ret more than five huntlred500)'Y Jo
❑I,a:owner of the property,or my whowage:as their sole compeneatlon,will W WOOD SHAKES ❑
the work,end the Structure Is not Mtended for (Sec.7044,Busnest and Protest-
' elarM Code:The Contractors lienee law ply to an owner of pmpady who builds w WOOD SHINGLES
Improves thereon,and who does Such work cmanplg7ae:,pprr��''ketl that ❑
such Improvement:era not Intended or offe . I,'thebulMiripw.IKlprovement G
IS Said within one year of completion,the owrrer.builder will hew the burden of proving that he did OTHER (SPECIFY) (/
not build or Improve for purpose of sale.j..
❑I,as owner of the property,am exdueiwly contracting with licensed contractors to construct �
the project(Sec.7044,Business enol Professions Code:The Cantradort Llaense Law does not PROVIDE I.C.B.O.REPORT NO. ?b��
apply to an owner of property who builds w improves thereon,end who eoniraero for Such projects
with a cwtrector(s)licensed pursuant to the Convectors Ucense law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B IS P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of Me ldlowing dedwetbn:
❑I haw end will melnteln a Certificate of Caneent to self-Insure fw Workers Compensation, Building/�
as provided for by Section 3700 of the Labor Code,for the performance of the work for which UIS /
Xper I he eu O'will malnteln Workers Compensation Ineurence,as required by SmOw 3700 of /Z/ �(�\ �. Seismic / 3.D
e bor Cade,fw the performance of the work for which this permit Is all My Workers / / .3 a
Compensation Insurance carrier and�Polkiy number are Total ( 7
Carrier X7'2 PdicyNo. / j PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' Q
COMPENSATION INSURANCE N.CQ qn
(This section need rot be mmpbted If the permit is for one hundred dollars($100)or lase.)
any perrtify soon in any manna ago as to of
ome subjjeect t mthis o permit Cwnipa aamn Laws of Cali-- All roofs shall be inspected prior to any roofing material being
forma. 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 ahold become Applicant understands and will comply with all non .Dint
"load to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP P Y P
with Such Provisions or this Ixmnil that be deemed revoked. s0 lations.
I certify that I hew read thio application and state that the above Information la correct I agree
to empty with all dry arta county of drancas and stere Iowa the
e-bullring cons party f,vend All roo—less or better.
hereby authorize representetlws of thio city to enter upon the ebwe mentioned property for In
upection
(We)agree to leve,Indemnity end keep h any
w as the City of st said Ci apemen Ileumlablififfies.
udgmenta,cosU and axpent which may In any way accrue egeHsr said Cly In consequence
W thegmnting d MIS Permit" SIGNATURE OF APPLICANT _ DATE
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