R-6470•
Cj
OFFICE COPY
PERMIT R_ 64 7 0
APPLICATION FOR CITY of CUPERTiNO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
C4�dNk'pogT 41 1j AV 2
'
t/G (/
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZABDOILIS FIRE AREA .
A
�' /'O TW
r�`'U_
YES ❑ N jres— starq Class A '
NAME _Vl/ 1 \ UU11aa �N��
OOIJ
erably iced.
roof assembly is required.
NO Initial LC.B.O. R
C1 9100 ,,_,I
WL4)
51'
- EXISTING ROOF COVERING
ADDRESS �� , �
/o^)
6 6.'6
NUMBER OF EXISTING COVERINGS /
PHONE
,
CONTRACT
//S��� _ /I����� /] _ /`,,
NAME t, FD110A R006V CID, �Q
'TO BE REMOVED TO BE RETAINED
�
ADDRESS t595 5, 5? JT. G _
_�N4/5-i
TYPE OF ROOF COVERING
CrrY&ZIP J�^'�� t otie,4+- Z
EXISTING
�Q —7th,
PHONE �0R'^aa3 — / / 7:7
BUILT-UP ROOF
LICENSE
00
NUMBER
ASPHALT SHINGLES ❑
• LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9 (commencing with Section
WOOD SHAKES ❑
7000), of Division 3 of the Business entl Professions Cade, entl my license is In lull force and
-
ened. r 3� nn
License Clens Lk. Number �:/Rn
17!19�ivr:>
WOOD SHINGLES
D
Dais b'9� G)i (D
OTHER (SPECIFY) ❑
OWNER-Bontra UILDER
OWNER -BUILDER DECLARATION
APR 16 1999
hereby reason.
Any city License Lew for the
Bu Cees em exempt from the
PROPOSED
mess ag
(Sec. 70315, ee Code: Any city or county, which requires a permit
, ve and e:
alter, Improve, ssindsalranithat he priortoIts penance. shop
phsh, or repair e
demto
BUILT-UP ROOF
app,consQct,orsucnpermit file to provisions
the pro of the
applicant for such parent to lib a signed statement Met g Is licensed p 000) of
of Me Lew (Chapter B a with Section 7000) of Dfor me 3 0l the
By
sscontractorsandfLlconse
Code) or that he le exempt M,refr
Is ex pt hi and the basin for the dant
end Pmllation
ASPHALT SHINGLES
f
exemption. Arty Wootton of Section 70315 W any applicant for a permit subjects tib applicant to
do a to
exemption,
a cMl penalty of not more than five hundred dollars ($5W).):
WOOD SHAKES
❑I, as owner of the property, or my emplpyros with wages as their ads compensation, will do
❑
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Badness and Profen.
'
sone Code: The Contractors Ucense Lew does net apply to an owner of property who b Ikf f or
WOOD SHINGLES ❑
Improves thereon, and who does such work himself or through his own empoyees, provided that
Such Improvements are not Intend" or offered for hale. If, however, the bulking or unwoyement
Is sold within one year of completion, the owner -builder will have the burtlen of proving that he did
OTHER (SPECIFY) ❑
not build or Improve for purpose of lido). .
0I, as owner of the property, am exclusively contracting with licensed contractors to cmrrelnct
the project (Sec.7044, Business and Professions Code: The Comredora Ucense Law does rpt
PROVIDE I.C.B.O. REPORT NO:
appy to an owner of property wino builds or Improv>n thereon, and who contracts or such projacls
with a contractor(s) Ikenead pursuant to the Conaactoes Lkenae Lew.
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 em exempt under Sec. ,B 8 P. C. for We reason
owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKERS COMPENSATION DECUBATION
I hereby affirm under penalty of penury one of Ma following doclere lon:
❑ 1 have and will maintain a Certillrale of Consent to "114miure for Workers Cumpeasation,
Building
g
as provided for by Section 3700 of the Labor Cade, for Me perionrance of the work for which this
gem°
have and will maintain Workers Compeoedicn Insurance, required by Section 3700
/ ' L C�
�1 IU
'% %,�!
q
Seismic )
as of
tM Code, for the performance of ties work for which this permit le Issued. My Workers
orode,
Y
O�� / /v•OQ
Total
Compereatkm Ineu nce carder and Pd cy number are:�g
Carrier / PolicyN�/K �y3*10-03
PERMIT AU TION
DATE
CERTIR OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C❑
(This eecgon meati not be completetl If the pertnit Is for one hundred tldlere ($100) or lase.)
I certify that In the performance of the work for which this permit Is Issued, I shall not emW oy
nner
any thereon In any maso an to become subject to the Workers' Compensation Laws of Cdh
All roofs shall be In ted prior to any roofing material being
fomb.
installed. If a rqA isinstalledwithout first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPUCANT: ll, after making thin Certiflcab of Exemption, you should become
A ficant understands and will cora with all non point
PP comply P
subject to the Woekars' Compensation provisions of Me Labor Cade, you must forthwith comply
with such provisions or this permit shall be deemed revoked.
Source regulations.
I tartly that I have rend this application and stet, that the above Information Is correct. I agree
to comply with all city and county ordinances and Mate lave reletlrg to bdaing construclk,n, and
All roof coverings to be Class"C"or better.
hereby suftrin repreeenletivoe of INS city to enter upon Me above-mentioned property for In-
spectfon purposes.
(We) agree to neve, Indemnify and keep hamnless the City of Cupertino against Ilabilltles,
Judgments, ween and expenses which may In any way accrue against said CIry In consequence
of are granting of this penult.
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION .
OFFICE COPY