R-6668 �9. 1 PERMIT R_ 6668
LICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT - (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 MVS OF PERMIT ISSUANCE OR
1B0 MVS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
a[ RESIDENTI COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
//rJ C L VES ❑ If yes–I understand that a Class
NAME(70^ �L_y� "r1lJ Je.7,✓/GBS root assembly is required.
NO ❑ Initial— I.C.B.O.p
ADDRESS-7--r?
o-7- th jOIL 6rcn* EXISTING ROOF COVERING
PHONE 7 p –0 3 3 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S TO BE REMOVED TO BE RETAINED
NAME L.L{' Sea_So�a- QPf<>
ADDRESS TYPE OF ROOF COVERING
CITY&ZIPAS-SoCe iir// .
EXISTING
PHONE 3 BUILT-UP ROOF ❑
LICENSE -
NUMBER ASPHALT SHIN S
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commerx9rp with WOOD SHAKE
7000)of DNlslon 3 of the Business and Professions Code,and my license Is In full for nd
al 3 ys� �� O 7 OODSHING S JUL 15X99
Ucen°e Clem Uc.Number !� d �y
Deb l Y� F I Contractor A'If SCySo +S �-�–b _ LR PE Ig ❑
OWNER-BUILDER DECLARATION y
I hereby af8mr that I am exempt from the Contractors License Law for the blbwing reason.
(Sec.7031.5,Business and Professions Code: Any dry or county which requires a pemn to
construct,after.improw,demollah,or repair any structure,ppriorto its leauerra,also requires the BUILT-UP ROOF ❑
applicant for mon permit to file a signed statement Net he b licensed pursuant to Ne prvvWons
of the Contractor's License,Lew(Chapter B(comm with omSectionand 7000)si Dfor Me 301 the
Business and P iolml lm Cads)or that he Is exempt erfora and the hale for Ne start to ASPHALT SHINGLES
exemption.Any f not on of h allon hundred
by any sft1 SG nt kir a permit subjects the applicant to
°WII penalty of rtm more Nen five hurWretl tlollers(35oD)J:
❑I,as owner of the properly,or my employe"with"gee m their sole compensation,will do WOOD SHAKES ❑
the work,and me structure Is not Intended or offered for ssie(Sec.70",Business and Profits.
films Code: The Contractor°ucanm Law do"not apply to ea owner of property who builds or WOOD SHINGLES
❑
Improves thereon,and who does such work himself or through his own employees,prmdod that
such Improvnt
emes are not Intended or oller°tl for safe.If,twwever,the bulkling or Improvement
Is wW within one year of compbtlan,the owner-builder will have the burden of prwng mat"did OTHER(SPECIFY) ❑
not WIW or Improve for purpose of sale.).
❑I,"owmrcf Maproparty,emwclu"lycmtractl with llcemed centranora to construct
Na project(Sec:70",Business and Professions Cod°:The contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
appy to an owner of property who Wide or Improves thereon,and who contracts for such projects
with a conbactor(a)licensed pure t to the contractors Llcenm Lew. PROVIDE MFGR. INSTALLATION SPECS.
-71 am exempt under See. ,S a P.C.for his reason
°cometDat°
WORKER'S CpaPENSATK)N DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I her"affirm under penally of pedury one of me following dadaretlon:
❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, BUlldln
"provided for by Section 3700 of the Labor Code,for the Performance of the work for which this
pemnit Is leeuetl. �O O Seismic
1A+h°ve
and will the part Workers Compensation work on Inwrarce,ae rmit is I su Section 3]00 of
Comp ear
Code,for the pertormand of the work for which Nls permit 1°teals".My Workers Total g�
Comperaatb\n In)eurenn center and Policy number are.
cairl°r'�/1(G itOUA4 -H"S- Policy No.60C30-5--e000 PERMIT AUTHORIZATOON DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.Ct] — !r
(This a°ctlon need not be completed It be Permit is for one hundred dollars($100)or Ion I /J
I certify that In the performance of the work for which this permit a bored,I shell not emptoy
any Person In any manner so m to become subject to the Worksm'Cocpeneatbw
n Le °of Csti. All r s shall be inspected prior to any roofing material ing
1ornlp' in ailed. If a roof is installed without first obtaining an
Date Applicant spection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you shcuW.become Applicant understands and will comply'with all non int
subject to the Worker°'Compensation prWsom of the Labor Code,you must brlhwlN compy pP PO
with such provlelon°or this permit mall be deemed rpepked. Source regulations.
I cerdly Nat l have read this application entl state that the above Information l°correct.I agree
to comply withall city and count'ordinencesand stere laws raising to building and All roof COV rin sto be class"C"or better.
hereby authorize representahm of this cry to enter upon the above mentbrud property kir In-
epectim(We) purpose .
V__`J. 7—/—/
(We)egr"to rave.Indemnify y end may
I hay a y the Clry of Cupertino sad
ayalnn siabliftes.equence [
of he your cast°entl expenses which may In any way emus against sato Cly In consequence SIGN RE OF APPLICANT DATE
of the tin of this permit.
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