R-6536 J r
PERMIT R_ 6536
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION P RMITEXPIRATION
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 -
Oil V e, v4! RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
II y YES ❑ II yes=1 tlfldar6l8lld tlat a Clens A
NAME '6.1, K / 1yY✓y root assenbly is regtd1
�7
NO E] InNel I.C.B.O.b
ADDRESSuZ 9 4' l/N�4 t ✓, PC,e M•-C _-/m w .T2s P EXISTING ROOF COVERING
PHONE 9 7—' S- 7 3 3 NUMBER OF EXISTING COVERINGS C_0 +�a
CONTRACTOR'S (!!a /,./
NAMEI P /ce_r l //(pu prJp i�3 � -we
NAME REMOVED TO BE RETAINED
ADDRESS �s C nn ` '/ / TYPE OF ROOF COVERING
CITY B TIP
PHONE (0 a Q BUILT-UP ROOF ❑
LICENSE
NUMBER �I`T 0ail5- ASPHALT SHINGLE
UCENSED CONTRACTORS DECLARATION EB399 I hereby affirm Met I em Ikensed under provisons of Chapter B(commencing with Section WOOD SHAKES
7000)of Dklskn 3 of the Business entl Profes ions Cade,entl my Ikense Is In full force Ao0N0c1- WOOD SHINGLESUcanse Gass �'3 9 Uc.Number dOD/sDate Conneclm -Ft .r OTHER(SPECIFY)OWNER-BUILDER DECLARATIONPROPOSED .
I hereby affirm that 1 am exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Business shot Professions Cade: Any city or county which requires,a permit to
construct,atter,Improve,demolish,or repair any structure,prior to its lesuence,also requires the BUILT-UP ROOF E)applfcent for such pernOt to file a signed statement that he Is licensed pursuant to the provisions
of the em an Pre Ucense Lew(Chapter B Is exa ofnp wish Sectionand 7000)of DMebn 3 of the
Bu mptio end vo lotion f Code)or that he u exempt antfor m entl the bads for the i lisped ASPHALT SHINGLES
exempt en.Anyf not m n pl hactbn 7031.5 by any applicant for a permit eugeca Ne applicant to
e dNl penalty of net more than live hundred tlosere($600).1:
❑1,as owner of the property,m my employees with wages as their sole cornpensetlon,will do WOOD SHAKES El
the mark,e: tee ontrare Is not Intended cor oarl not for oak n(Sac.ow er of Busirope tya and Probe-
impr Cede:The,an who
Licence law damerat apply to his
of property whoWilkieor WOOD SHINGLES ❑
Improves thereon,and hot does such work himseoffered
or.If.ho Ne own employees,Improvement ed that
such Irtprowmena are rat Intended or offered lar oak.ll,however,Mm enobuilding or g met he did
h soldwithin
or improve
for purpose on,the owner-builder will haw the burden of proving that he db OTHER(SPECIFY) ❑
_ rwt build or Irtprow br purpose of eeleJ.
❑1,as owner al the property,em excluaWy contracting with Ilceneetl cmtadors to construct
Me project(Sec.7044.Business and Professions Code:The Contractors Ucenae Law do"no PROVIDE LC.B.O.REPORT NO.
apply to an owner of properly who build,or Improws thereon,and who contracts fur such projects
with a contnaons)Ilcensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
E]I em exarnpt under Sec. ,B 8 P.C.for this reason
owner Date
WORKERS COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penally of perjury one of the lolovdrp dedaratbn:
❑1 hays and will maintain a CerlHicate of Consent to self-Insure for Workers Oompansadm, Building as provbed for by Seaton 3700 o the Labor Code,for the parlormance of the worn for which this O
permit Is issued. �• Seismic G n
11 hew
and will maintain Workers Compensetlon Insurance,as,raquired by Section 3700 of
the ,ar Code,for the pedormence of the work for which this penult a Issued.My Workers / 7, 4n
Camperaatlonl nc oPol numberare: i3 �, �to Total
Carrier SS g Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ .f'
(Thi5 section need no be completed If the permit Is hr me hundred dollars($1010)orleas.) �� y ^ I C3
I cerefy that In Me parlormance of tee work for which this permit is Issued.I shell not employ
any ponsm In any manner so as to become subject to the Workers'Compensation Lowe 01 Cao- All roofs shall be inspected prior to any roofing material being
f0ma _ installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subject tooEtheOWarkere Cmpel,after malding fts Certificate of Exemption,you neatlon pro ssbne of the Labor Code,you must b�with�°mmb Applicant understands and will comply with all non point
with such provision or this permit shell be deamed revoked. source regulations.
I certify flat l have read this app11ca8m and ante that Me above information is correct.I agree
to comply with all city end county ordnerweeshM state laws relating to bullmng construction,and All roof coverings to be class or better.
hereby authorize represenatim of this city to enter upon tin al o e menOmed property for In
spectlon purposes. 070
(We)spree to save,Ioemnlfy end keep harmless Me Gty of Cuperllno against sedfi8es.
Judgments,costs and expenses wfdch may In any way accrue against Bald City In consequence
of the granting of Mk permit. SIGNATUR A LICANT DATE
;• PRE-INSPECTION: PLYWOOD: IN- ROGRESS: ,
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