R-6667 PERMIT
PLICATION FOR CITY OF CUPERTINO NUMBER R 6667.
" INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED,
WITHIN S F DAYS OF PERMIT ISSUANCE OR
WI DAYS FROM LAST CALLED ISSUANCE
INSPECTION.EO
BUILDING ADDRESS
8icY \ a
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
//�` v y YES ❑ If yes—I taldersland that a Class A
NAME S�59'•'k/W M �- Mk�JJ S.f!t/1<.2 C� roof assernhly 1s required.
NO ❑ Initial LC.B.O.tl
ADDRESS7,,;2 7 im;yOfS(�V Ayj, cGrn'Tc& G4• -
EXISTING ROOF COYERING
PHONES NUMBER OF.EXISTING COVERINGS
CONTRA
NAME S'da Sm'k g `o- TO BE REMOVED TO BE RETAINED
ADDRESS /
TS / ( - �3 Gr��z TYPE OF ROOF COVERING
CITY&ZIP bT rTor /LInQ S! l r
EXISTING
PHONE a 78"- ot 336 BUILT-Up G�—�-�—
NUCENSEMBER S� D$" ASPHALT GLfs6% a❑
TION
I hereby affirm that I am carent unLICENSED�ovlebnsSoff Chapter (commencing with Section WOOD SH JUL 5 1 '
]000)of Division 3 of ha Business and Professions Code,anal my license IS In full force end J V L
effect. G/ }� WOOD SHI LES
umnsaCch. (/C 3 7 Uc.Nader ( � Z/O V ❑
Date—J—I/ - 7 f connector OTHER(SP (`g]
OW44ER-BUILDER DECLARATION w PROPOSED
I hereby affirm that I am exempt from the Cmtrsctors License Lew for the fd cMng n.
(Sec.7031.5,Business and Profession,Code: Any dry a county which requires e o
construct,alteq l^pnov'e,demdish,or repair any strumme,worto its Issuance also r Ire h BUILT-UP ROOF ❑
applioant for such permit to file a signed Statement that he Is licensed pursuant to th
of the ss an,1lors Ucenaa Law(Chaplet B Is ex a pt t with therefrom
enc!7000)of fo of the l
exelneev end violation
Code)on that he la exempt therefrom entl tits beefs for ap alleged $P ALT SHINGLES
exemption.Anyyf not more
of Section Inumdr by airy appacenl for a pemYt subjects the eppikent to
e tlNl penalty of not mare limen five huMred dollars($500).):
E)1.as owner of the property,or my amp""with wages as their acts compensatlm,will do DSHAKES ❑
the work,and the structure B not Intended or offered for sale(Sec.7044,Business and Profes-
sions Code The Contractor's License Law does rot apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thareon,and who ddee Much work himae8 or through his own employees,provided that such Improvements are not Intended or offered for sale.It,however,the building or Improvement
Is sob within one year of completion,me owner-Wilder will neve the burden of proving that he did OTHER (SPECIFY) ❑
not build a Improve for purpose of Male.).
❑I,as owner of the property,am bxduelvety cmirectlrg with licensed contractors to construct
the project(Sec.7044,Buelneee end Professions Code:The Commuctote Umnae Lew does not PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who bulltls or Improves haraw,and who contracts for such projects
whim a contrectogs)licensed pursuant to Me Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS.
1 em exempt under Sec. ,B&P.C.for tris reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
'
I hereby affirm under penalty of Perjury one of the folWMng declaration:
❑1 have and will malntsin a Cartflkate of Consent to seltaneure for Workers Campenaaiion, d BUIIdIn
as provided for by Section 3700 of the Labor Code,for the performance of the work for which Mie / rZ2�
permit Is Ieauetl. JOO SBISmIC
I have and will the performance
Workers Compensation I hick tro;perequired M Section 37M of
Worker's ./
_ire bar Cade,br the lain Worker of the Compensation
tar which Ise permit is dIfteaued.My Workers
Compenlee/tlpn tnaurence tamer and Policy number ere: Total
Cameryi1 �4.woV<F .=.JC. Policy Nz c3oSRO T PERMIT AUTHORIZATIO - DATE
CERTIFICATE OF EXEMPnON FROM WORKERS'
COMPENSATION INSURANCE N.C[] ~/�
(This Section need not be completed If the permll Is fa one hundred el (5100)on ba.) t f� YY
1 minty that In the penonnecoe of Me work for which this permit Is issued,I shell not employ
any person M any manner so as to become subject to the workers'Compensation Lave of h Ae In rior to any roofing material being
lomla. . instal �d. If a roof is Installed without first obtaining-an
Data Applicant in coon,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: II,akar malting IRAs Certificate of Exemption,you should became A licant understands and will comply with all point
Subject to Me Ww Ms'Opmps d the L
aneation pro,dMoreber Cade,you must forthwith mmpty, p Y non p
Man actin proviscne or MU permit shalpm deemed revoked. Source regulations.
I certry that 1 have read his application and state that the above Infor ustim is correct I agree
to comply with all dry and county ordinances Mrd elate laws rMaling to building construction,and All roof cove gs lass"C*or better.
hereby authorize representatives of this cliy to enter upon he above-mentioned property or In-
apect purposes.
(We)
tsgree cases, °eve.Indemnity entl ka I h ny way the City of Ct Said Ci y Inagainst Iaqlubue.ee.
of a grantinhis pand ermit. wblch may In arty way accrue epdnet veld Clry In casequerx:e SI NAT RE 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 ACCESS TO ROOF SHALL.BE PROVIDED FOR INSPECTION
OFFICE COPY