R-6669s
11
g` 3 PERMIT
U BER R- 6669
LIGATION FOR CITY OF CUPERTwO
y. INSPECTION DIVISION PERMIT EXPIRAT101
REROOF PERMIT (408)T77-.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE CR
160 DAYS FROM LASTCALLED INSPECTION.
BUILDING ADDRESS
(J
FaC `ct,
I IL
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
(\� cYES
NAME CoJ�w...> w \ \ u' �v`� • v e'rU1 C e
❑ If yes — I understand that a Class A
mot assernWy is required.
NO ❑ Iniflal I.C.B.O. C
-
� 1
VR f'S r �y �U
EXISTING ROOF COVERING
ADDRESS— V e'\-\ _
O5 V 0Ke$--i
PHONE
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
��
TOBE REMOVED TO BE RETAINED
NAME _f
ADDRESSc✓
CKs S.tS•CQI•F�//
TYPE OF ROOF COVERING
cITY6ZIP L eon%JIG. Srr'
EXISTING
? g D 3 3 O
PHONE[ko$7
BUILT-UP ROOF ❑'
CENSE
NUMBER SaaL (O g
ASPHALT SHINGLES ❑
' LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under pronskxa of Chapter B (oommancing with Section
WOOD SHAKES .�'
7000) of DMslon 3 of Ne Business and Prbfemlon Code, and tryIloanae b In full force ane
effect.
y.Sz 10
WOOD SHINGLES ❑
Ulcerate Cleat _ UC. Number
f/ /''
R CIFY) ❑
Date �2_ Contractor r/,1 Ar ,SC4
_
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's Loan Law for Ne Idlowing reason.
(Seo. 7031.5, Business and Professions Code: Any dry or county which requires a permit to
mntrucL alter,Improve, cemolleh, or repelr any Structure, pprbr to its Issuance, also requires the
BUILT-UP ROOF '❑
appllcant for sudr permit to file a signed testament Net he ie Ikensed pursuant to the provlelora
of theContractor's License Law (Chapter 6 (wmmsmcm, wIN Section 70 X1) of Division 3 of the
Business entl ProMslem Coda) or that he Is exempt therefrom ark Ne basis for the alleged
ASPHALT SHINGLE
exemption. Any violation of Senon 7031.5 by any applicant for a permit subjects the applicant to
a dull penalty of not more Nen frw hundred dollars ($K(ff.):
WOOD SHAKES '
C] 1, m owner of the property, for my employees with wages as, Meltable compensation, will do
the work, ark Ne structure is not Intended for offered for Sale (Sec. 7044, Business and Profos.
scone Code: The Contractors License Law does not apply to an owner of property who builds or
WOOD SHINGL JUS
Improvise Nareon, and who does such work himself or though his own employees, resided est
7 "
such Improvements are not Intended or offered far sele. If, however, Ne bultllrq or Pmwowment
d
Is sok will one year of compledon, the owner -Wilder will have Ne burden of proving Nat he did
OTHER(SPE ❑�
not Wlle or Improve for purpose of sale.).
❑I, as owner of the property, em exclusively aontractln with llconsed contractors to conebuct
Ne project (Sac. 7044, Business and Profemlons Code: ha Conbecto's License I.ew does not
PROVIDE I.C.B.O. R NO.
apply to an owner of property who builds or Improves thereon, and who contracts for such projects
with a cbntractor(s) licensed pursuant to Ne Contractors License Law.
PROVIDE MFGR. INSTALLATIO CS.
❑ I am exempt under Sac. ,B & P. C. for Wal reason
Dwne( Data
APPLICATION DATE VALUATION
PERMIT FEE
' WORKER'S COMPENSATION DECLARATION -
I hereby affirm under penalty of perjury one of the following dederetbn:
❑ 1 have and will maintain a Certificate of Consent to self -Inure for Wotlsrs Compensation,
- dD
Building
as provided for by Section 3700 of the Labor Code, for the performance of Ne work for which Nle
°ef�`le�a0ed'Insurance,/
4 .�
SOO
1,
V
Seismic
pi hew and will Worker's as required 15 3]0001
i
the p&n f Me waatan hickthis I u d. My
in or Code, for the pedormerrce of me work for which NIS permit a Issued. My Workers
-Compenet1
n Insurance carrier end Polley number era:
Total
� )
Carrier �� ` (' 0- N O J �N S ' Policy No. iYG 30,rL000 Y
5ERMff-AVTHORIZATIONP
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
�ar-
COMPENSATION INSURANCE N.C{]
(This section need net be completed If Me pehnit Is for one hundred calls. (S1C0) or lees.)
'
�(/\
' I cortHy, Net In the performance of Ns worx for which No parml Is issued, I shell not am toy
any parson In any manner So m to become subject to Ne Works., Ccmpenaatbn Laws of Can-
'
All roof^ I be inspected prior to any roofing material being
. hernia. -
Inst . If a roof is installed without first obtaining an
Date Applicant
in Ion, I agree to remove all new materials for inspection.
NOTIbecame
eCor of ode, st forthwith
on npkrn�bns
A plicant understands and will comply with all non point
subject to MeW rk arise of Me Labor Ccomply
with such provolone or this permit she be deemed revoked.
source regulations.
I cenlfy that I have read this application and Seta Net the some Information Is correct. I agree
to comply with all city and county ordinances and state laws reletNg to building constmcdon, and
All t0 lass "C' or better.
h�biyoreu�ze�rasontetives of Shia city to anterupon the ebovemenhonetl property for In
Ws
—/
19
(We) agree to Save. Indemnlly, mam and keep harme Clty_of Cupertino aaalnat mblltim,
Y
1Wpmard0. cosy and expenses, which may In arty way scmue against mid Cly In coraequerKe
SIGNA RE OF APPLICANT DATE
of the granting of this parmit '
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