R-6218 PERMIT R_ 6218
APPLICATION FOR CITY OF CUPERTINO . NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF-PERMIT (408)777-3'2'28 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
9 /}/��)^ o ,, \/ /n 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING
ADDRESS 7 1 r `� `�� ka
RESIDENTIAL COMMERCIAL OTHER
HAZARDOUS FIRE AREA ,
VES ❑ Nyos—Is
antltheteCasA
NAME "�„r � //CC.Ily7-�R4M woof assemblymblyisis required. -
NO L7 In1fia1_j-4-'6 LC.B.O.M
ADDRESS -- EXISTING ROOF COVERING
PHONE 4404 NUMBER OF EXISTING COVERINGS I
CONTRACTCONTf1ACTPlR7 J
TO BE REMOVED � � 70 BE RETAINED
NAME
ADDRESS C_ /7 TYPE OF ROOF COVERING.
CIN 8 ZIP - O G 'S� EXISTING
YOJUPHONE(L0 0) 4?L 3 —6 3 7 3 BUILT-UP ROOF ❑
LICENSE SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chaptei 8(commencing with Section WOOD SHAKES
7(Y00)of Dfv sp 3 of the Business and Profasalans Code,and my license is In lull force and
eHeLa. WOOD SHINGLES ❑
Ocense Clara Llc.Number FIX 7 O
Date �44 O Contractor • • OTHER(SPECIFY)
O'MIER BUILDER DOr
E es Lice I PROPOSED
hereby aHlrm mat am pxempl imn the COnimdolp License Law for Me urns ag reason. �•-,,
(Sec.7031.5,Business and Pmleaafone Code: Any city cr wunty which
requlras a perrdl to..•-
construct,alter.Improve,demotleh,or repair any stmcmre,odor to its laavence,abo requires the �. BUICLI}UP ROOF E]applicant far ouch permit to file a signed statement that he Is licensed Pursuant to the ns �� I, ^
of the Contractors Lkenss Lax(Chapter 0(commencirg 011he with Section 7000)of DNlelo 3
Sualrreea and Profession Code)or that he Is exempt Merefrom and Me basis for th O e l ASPHALT 'G ES
womptlon.Any Nolallon of Secton 7031.5 by any appllcent lore pennll eubjecte the fo
e dull penalty d not more than five hundred dollere(S50D).): I �Qµ,.•,t(��,(]] -
❑l,ee owner 0l the property,or my employees with"gas as their We compeneetlo�lpr{W.�Inll tlaJA 1.�t W111 S ❑
Me work,end IM structure is not Interked or offered f«said(Sac.76 ,Buflnesa eMfP,Wlee
Rion Code:The Convectors License Lew does not apply to an owner of prof wfa tls« WOOD SHING ES
Improves Merron,and who does such work himself or through his own enplcr='pro+ 1 ❑
such Improvements ere rat Intended or offered for sale.If,fawever,the bulldIng or Imp t d
is sold within one year at completion,Me owner-builder will he"Me burden of proving th SPECIFY)
W Wild or Improve f«purpose of Bele.).
❑t,ea owner of Me property,em exdualvely cmhactlrg with Ilceneed contrectore to COnelrud
the project(Sec.70x4,Business and Pmfeselons Coda:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who Wilde or improves Merron,ark who contracts for such projects
with a contractor(s)licensed wri uant to the Coniredors License Law. PROVIDE MFGR.INSTALLATION SPECS.
I am exempt under Sac. ,B 8 P.C.'for this reason
0", - Data APPLICATION DATE VALUATION PERMIT FEE
. WORKER'S COMPENSATION DECLARATION
I hereby alllrm under penalty of perjury one of the following dedamtlon: C /� 7
❑1 have and will maintain a Certlrkam of Consent to selbinntre for Workers Comwnsatlon, / Building
Psprovided for by Section 3700 of the Labor Cade,for Me Performance of Me work i«which this �J�� /1��7d Buildingsmic �eZ �
I is leeued. �{/
have entl will maintain Workers Comperuration Insurance,as required by Secton 3700 of.
Me per Code,for the performance of Me work hr which this pentyl to issued.My Workrra
Co peruatbn�lnau` ` cyosier ark Polley num rare: Total ZO
Car ier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This ambon Treed Tal be completed it the permit Is for one hwdretl dollars(5100)or less.) 7
I cey that In the performance of the work for which Ws permit Is imam, shell not employ v
dll
arry person In any manner w as to become subject to Me Workers'Compentetlon Lowe of CeIF All roofs shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Date Applloant inspection,I agree to remove all new materials for Inspection.
NOTICE APP C : If,alter making this domficam of mroldn�tu should a aY Applicant understands and will comply with all non point
subject to Ma Workers'Com nsatlon rwislons of the Labor e,
with such provisions or We permit shell be deemed rawked. Source regulations. ,
I certify that I hew read this application and stale Met Oro above Infonnatlon is coned I agree ///J
to compry MM ell dry end county ordlnencea and state laws relating to lwllding constmdldn,ark All roof cow rings_Lo be class_ecr better.
hereby auMoHze representatives of this city to enter upon the abaro+ronboned property for In. Q
spectlon purposes.
(w
e)agree M sew,Indemnity entl keep Ma harmless City of CupeMlno agtint liabilities,
Judgments,costs and apensae which may In any way accrue against said City In coneaquence SIGNATURE O APPLICA ATE
of the granting of th15 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 '