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R-6467E E • PERMIT R" 6467 APPLICATION FOR CITY of CUPERTINO NUMBER . INSPECTION DIVISION PERMIT EXPiN 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 AADCD�RESS 19 ©) t I10 RESIDENTIALJL COMMERCIAL OTHER OWNER'S. HAZARDOUS FIRE AREA r m� YES [3 It yes — I unOerWand Clot a Class A NAME W �+Jt I/✓ V✓ ry► !�ry{l roof assembly is featured. NO Initlel I.C.B.O. tf EXISTING ROOF COVERING l`JILI/�W�+/rl ' ADDRESS `�J NUMBER OF EXISTING COVERINGS / PHONE 1 pC[7 CONTRACTOR'SS],r1 NAME ��7 Y I ` ��1�'R O�-�n�d 1 C7•��-` TO BE REMOVED TO BE RETAINED ADDRESS* s I�rX}I S�•, �7A+I) of 5 �i2 16 T� PE OF ROOF COVERING clry & P 16 k EXISTING r (y —13^ PHONE 1 O�-7:7 BUILT-UP ROOF .LICENSE NUMBER 1-74900 ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby off. that I am Ilconastl under provisions of Chapter g (commencing win Section 'WOOD SHAKES ❑ 71 of DM,en 3 of the Susloess and Professions Code, end my license Is In full force end effect /— �1 Ucense Class a — 61 Lic. Number / 9 'IF. WOOD SHINGLES_ P) �-1- l6'S �] ��1 fQytyh �'I/ai Oene , Contractor OTHER (SPECIFY) PROPOSED APR 16999 p OWNER -BUILDER DECLARATION hereby that am axempl from Mf followuires ng reason. Lew fixis Buti Any which (Sec. ]ct, BImpro a and Cade: Any to cry or sous , e: arty or county re orolessk rep requires a paitires alt prifor to Itslicense lee also construct, Improve, demto BUILT-UP ROOF for such permit file signed stireny mentthte, rsuant to the tib a Chaste statement that he is licensed pureuent to the pro oftheapplicant al the a Lew (Chapter a with Section ]000) of to 3 0l the of the and ss Prof sense Business end h is ex Code) or that he le exempt therefrom and Me bees, for the pt tl for ASPHALT SHING SAY a V10tatim of ion of Section 7031.5 by any applicant for a permit suWecta the applicant to en. Anyf scant to cent not e chit Penalty of not more fhBn Ilse huntlrad dollars ($soo)J: ' WOOD SHAKES []I, as owner of the property, or my employees win wages of their sob compensation, will do ❑ the work, and the structure Is not Intended or ofbred for vele (Sec. 7044, Business and Profes. Sion, Coda: The Contractors License law does rot appy to an owner of property who bulkle or WOOD SHINGLES El Improves thereon, and who does each work himself or through his own employees, provided that such Improvements arenot Intended or offered for sale. If, however, Na building or Improvement issold Wffiln me year of completion, the owner -builder will have the burden of proving Met ha tlb OTHER (SPECIFY) Elrot bulb or Improve for r purpose of sa 0I, an owner of the maidenly, am "clualV,ly contracting with licensed contractors to Construct the project (Sec. ]old, Business arta Professions Code: The Contractors License taw dose not PROVIDE I.C.B.O. REPORT NO. apply to on owner of property who builds or improves thereon, antl who contracts for such prai with a cmttactogs) licensed pursuant to Me Contractor'a Lkoonse Law. PROVIDE MFGR. INSTALLATION SPECS. ❑ 1 am exempt under Sac. ,B & P. C. for this reason Owner Date APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION /f I hereby affirm under penalty of perjury we of the following declaration: ' I have add will maintain Certificate Consent to for Workers Compensation, ❑ a of self -Insure as provided for by Sooner, 37DD of the Labor Code, for the performance of the work for which MIs perm•N Iso atl. _ �O l,i BUI dlhg O [� funds end will rtalniSin Warkere Compenee0on Insurance, m requlratl by Section 3]00 0l 1 I / /X V < Seismic the Labor Code, for the performance of Me work for which MIS parmit is blued. My Workers I Total Compensation I��ns�uu�ra``o�e�'cartler and Polfcy number ere: ���� ,',' �[•� Gob(A✓V' �1er / PER THO ZATION DATE ' Carder Po10No.r"'KS11'%a✓''C CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.CQ (This Saki meed not be completed If the permit Is for we hundred "lam ($100) or lase.) �---�6 I cerdfy, that In the performance of Me work for which this permit U Issueq I shell not employ any person In any manner so of to become subject to the Workers' Compensation Lewis of Cali. All roofs Shall Kiridpected prior to any roofing material beifig fornia installed. If aXof is installed without first obtaining an Date Applicant inspectionr26ree to remove all new materials for inspection. NOTICE TO C mpetvatbnprovIf, after lalohnsoftheis �LeborCode.yyoumostforthwithcomte of Exemption, ou should p IV Applicant understands and will comply with all non point subecct oMeWorkers' with such provisions or MIs mmnit shalP,be deemed revoked.' source regulations. I cert Mat l hove read MIS application and state that the above lnemnetlm is correct.)agree to comply with all dry and county ordirtences ands Mate laws offering to building constructed. add AI��[[oof cove rings to sola "C"or better. K hereby repreeentathef of MIS dry to enter upon Mf above-mentloned property for In- n purposes. ape purpose. `J -q �� We) ane keep harmless Me City of Ct SaidrCi against habitee— (We) spree to save, Indemnexperts" s was edgminta, coats and expenses which may m em way accrue against seed Clry In coneequencaSIGNA�TUR -OF APPLICANT DATE ' of the granting of this perms. 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