R-6510 2 '
PERMIT
APPLICATION FOR CITY of CUPERTINO NUMBER R" 6 5 Z
INSPECTION DIVISION PERJYffT EXPMI N
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 190 DAYS OF PERMIT ISSUANCE OR
• 190 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS frjaµ„�: Apt II'',,� nn �dam10- 0.
(
^
1,0120 �1 UU-- RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDUUS FIRE AREA
YES ❑ If yes—I understand that a Clave A
NAME r t roof assembly is requited.
,� NO ❑ Initial I.C.B.O.b
ADDRESS—l4�— CM
�r..�} EXISTING ROOF COVERING
PHONE S 3,3 Q NUMBER OF EXISTING COVERINGS
CONTRAC R'S
cm Oerum. Pao TO BE REMOVED-------L—TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
y/ EXISTING
PHONE i7=�n�. �l G BUILT-UP ROOF ❑
LICENSE
NUMBER / -2Z-7? ASPHALT SHINGLES ❑
. l,7 .J
LICENSED CONTRACTORS DECLARATION
I hereby D aBinn that I emuid nese radar provlekxw of Chapter g(comma Is In with t Section WOOD SHAKES
7000)of Olvklm 3 o the Buelnase entl Proleeakxu Coda,and my kcanse le In lull force eM
offilWOOD SHINGLES
Ucenee Clew _ Uc.Number ��
Date -T 9 I Connector OTHER(SPECIFY) D (�=�
OWNER-BUILDER RanoN PROPOSED
I hereby alllrm that I am exempt from the Contractors License Lew for the following reason. MAY 141999
(Sec.7031.5,Buslneee and Proleeelo s Code: Any city or county which requir@a a permit to
construct,after,Improve,clan b,or repair any structure,prior to Its asuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is icenead pursuant to the provlslons
of the Contractors❑cera Lew(Chapter 9(commandnwith Section 7000)of DNIs Dir 3 of the
• Business entl Professions Code)or that he Is exempt therefrom and the bask for the alleged ASPHALT SHINGL B I
exemption.Arty vis a lon of Section 7031.5 by any applicant bre permit subjects the applicant to
e dog penelty of net more Nen I"hundred dollen($500).):
C:]I.as owner of me property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
III work,and the structure is not Intended or offered for sale(Sec.7044,Business and Probe- -
alone Code:The Contractors License Law,does net apply to an owner of property who bulks or WOOD SHINGLES ❑
improves thereon,and who does such work hlmeeH or through his own employees,prodcad that
such Improvements are not Intended or offered for sale.II,however,the bulking or Improvement
Is eek will one year of cumpletlon.I cwner-0lcor will leve the burden of provingthat he dd OTHER(SPECIFY) ❑
no bulk or Improv@ for purpose of We.).
0I,as owner of the property,am exdushrefy contracting with licensed contractors to construct
the project(Sao 7044,Business and Professions Code:The Contractors Ucerme Lew dose not PROVIDE I.C.B.O. REPORT NO.
appy to an owner of property who builds or Impro ra thereon,and who contracts for such projects
with a contractogs)literati pursuant to Me ContncMrs Ucenae Lew. PROVIDE Ml INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason
Owner DateAPPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under pendty of perjury one of the following declaration: -
❑I hove and will maintain a Certificate of Consent to self-lnsurefor Workers Compensation, Building ,)
as provided for by Section 37W of the Labor Code,for Me performerce of the work for which this 7�2�� ,,
permit Is Issued. O
❑I neve and will maintain Workers Conp@natbn eInsurance,as required by Section 3700 of SelSmlc
Me Labor Code,for the performance of the work for which this permit k blued.My Workers
Compensation Insurance carrier.{/an���ti�Pol�icy number are: /'n7 fA�—� Total
Carrier CERTIFICATE
�[.C71l.A Q,uaD Pellcy No. JeZ"D22�'5 PERMIT AUTHORIZATION DATE
CERTIFl OM EN EXEMATION INSURANCE
FROM WORKERS' -�
COMPENSATION INSURANCE /
section road net be completed If the Permit is for Ono hundred dollen($100)100)
Of" o or IwaJ �
I certhy that In ins performance of the work for which this permit is Issusd,I shop retemp Iq -'
any pawn In arty manner co u tobecome subjectto me Workers'Campeneetlon Lowe of CAIF All roofs shall a inspected prior to any roofing material g
fomla. installed. If a roof is installed 'Without first obtaining an
Date Appllunt - Inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,ane,modng MIs CoNflcator of Exemption,you should become Applicant understands and will comply with all non point
subject to Me Workers'Comparmadon provisions of Me Labor Coda,you must forthwith corrOy P Y P
with each provisions or this permit shell be deemed revoked. Source regulations.
I candy that I hew nod this application and stale that the abase Information Is coact.I agree
to comply with all city entl county ordinances and state laws relating to building construction,and All roof coverings to be class"C"or better.
hereby authorize repr@sentatkee of this dry to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to saw,Indemnify and keep harmlise the City of Cupertino agatrni liabilities. 7- i
futlpmenls,costs and expenses which may In any way acorue against said Clry In consequence
• of the granting of Mk permit. 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 '