R-6468..
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COPY
PERMrr R_ 6 4 6 8
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT ExPIRAnON
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.
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BUILDING ADDRESS AAPO,n-22 4f3
vr^� `moi—JJ JM1�
1 a QO
V
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
FIRE AREA
f ��y7`. I / /1 r
YES yes — I understand that a class A
NAME w b t WQ l �M.t CA;?j
roof assemblyIs required.
NO U Initial—I.C.B.O. N
to _
1 c o oI 1 h�
EXISTING ROOF COVERING
ADDRESS
` r/
.
26 26
NUMBER OF EXISTING COVERINGS
PHONE
TO BE REMOVED _ L TO BE RETAINED
CONTRACTO 'S _ Co!�,,
�F{'I, Zxy(,
�RG�-
NAME l l �'G"VI x -
,W
O�
CITY aEZP'✓�Ixi% S`� Th 52 lAW 3wr1 C*'
TYPE OF ROOF COVERING
EXISTING
PHONE �Q a q3 ' %G) %i
BUILT-UP ROOF [�
LICENSE
NUMBER OO
ASPHALT SHINGLES El
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I em Ifismsed under pr of Chapter a (commenting with Section
WOOD SHAKES ❑
Professions
7000) of DIVIMon 3 0l the Business and Proleaslons Code, end my license is in ford iwce and
abaci' -
C-3`1 09
WOOD SHINGLES �❑
auc"m Class Uc. Number
D .
`� Ott'
OTHER (SPECT ❑ '
Date ter' Contractor ,{H(,
OWNER -BUILDER DECLARATION
AP (�(�(7
-- R 1 6 1999
I hereby affirm that I em exempt from the Contractors License Law for the kllmv4mp reason.
PROPOSED
UU
(Sec. 7031.5. Business and Professions Code: Any city m munty which requires a permit to
- /
construct, after, Improve, demolish, or repair any structure, prior to Its issuance, also requires the
BUILT-UP ROOF
applicant for each permit to file a alpnetl statement that he Is Ilconsed pursuant to the provisions
B 1?q-Y
y
of the Contractors License Lew (Chapter 8 (commentlrmg with Section 7000) of Drialon 3 of the
Business and Professions Code) or that he Is exempt therefrom and Orae basis for the alleged
ASPHALT SHINGLE
exemption. Any violation of Section 7031.5 by any eppllcant for a permit subjects the applicant to
a clvlt penalty, of not more than five hundred dollars ($500).):
1, the their do
WOOD SHAKES ❑
C] u owner of property, or my employeae with wages as We compensation, will
the work,anti the structure k not InteMW or offered for sale (Sec. 7014, B Pune and Pmroa-
somCode: The Contractora License Law does net appy to an owner of property who bullds m
thereon,mi awho does such work himselfa through his Own employees, provitlatl that
WOOD SHINGLESx El
such Improvements are not keaMed or offered for sale. lf, however, the building or Improvement
Is sold within one year of comparon, the owner-Wllder will have the burden of proving that he did
OTHER (SPECIFY) ❑
not Culld or Impro for Purpose of sale.).
❑I,aaownerof.db property,emexduslvelymntmctin with lkeruedcontrectorstoconatruct
the Pmlect (Sec. 7046, Business and Professions Code: The Contractors Llcanse Law does not
PROVIDE I.C.B.O. REPORT NO.
appy to en owner of property who bullda or Improves thereon, and who contracts icr such projects
with a contractor(s) licensed pursuant to the Contractors Ucens, Law.
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 em exempt under Sec. ,B a P. C. for this mason
Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKERS COMPENSATION DECLARATION '
I hereby affirm under penalty of perjury one of the following declaration:
❑ 1 have ami will maintain a Certificate Consent to -Insure for Workers Compensation,
of self
mgrs ed roc by Section 3700 of the Labor Code, for hero perbrmertce of Nora work roc whltim Nle
perm
y�t���
D-17/(),00 .-y ^
Building
Seismic O
"aninsed.
have ami vdtl m Workers Camp ion as required by Section 3700 of
I
e pari work which this
the Can Code, for the p roe of me ware far which ihle panNt la lesuetl. My Workers
Campe/nteatk,x'mrIj,isurence
Total 0
carrier e�r�mdr Policy number are:
arhor
�i,.I
PEPINTAUTHO IZATION
DATE
carda60'' ro PolleyNo.WCSN5��03
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCEN.C[]
(This section need not M completed It the permit Is for one hundred ( dollars $100) or less.)
I certify that In the performance of the work for which this permit la Issued. I shell not at—
any parson In arty mamar so as to become subject to the Workers' Compensation Laws of Cell-
All roofs Shall nspected prior to any roofing material b ng
rornla.
installed. VX roof is installed without first obtaining an
Date Applicant
inspectio agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It, after making this CertiNCMe of Exemption, you should became
auojen to the Workers Compensation provisions of tiro Labor Cade, you moat forthwith comply
Applicant understands and will comply with all non rut
pP P Y Po
with such provisions W this permit shall be doomed revoked.
source regulations.
I mNly that l have read this application and Mate that the above Information is coned. I agree
to hereby authorize
all ctryand county ordinances and este law theladngtobendogcoproperty for
hereby authorize mpmaansdves of this city to enter upon the above-mentioned property for In-
idlr ngs to be pt better.
aped
e) agree to and keep hartnlees the City Capactins egelco Ilabllltles,
(We) spree to save, IM
`
expenses, w ai
gran cogs eM expenses which may In any way amore against said City... mnsequarmce-APPLICANT
k
of ft
olthe granting of iNe permit
SIGNATURE PL A T 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
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