R-6068;0100 M" Ave, y
As
•
PERMIT R_ 6 0 6 8
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION
REROOF PERMIT (408)777-3228 PERMIT EXPIRESIIFEWORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
' 180 DAYS FROM UST CALLED INSPECTION.
BUILDING ADDRESS evD
10?_6a OM49
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
Q
�OI�%
YES ❑ If yes— I understand that a ClessA
NAMES fVe,�°U
roof assembly is required.
NO ❑ Initial I.C.B.O. Y
Z ,(
13 O DO1/V.A...7C, S 1
EXISTING ROOF COVERING
ADDRESS
57a 96 ;3 0
NUMBER OF EXISTING COVERINGS
PHONE Z>•
TO BE REMOVED TO BE RETAINED
CONTRACTOR'S
NAME
ADDRESS
TYPE OF ROOF COVERING
CITY d ZIP
EXISTING
f
� �.6 Z� l I
PHONE
BUILT-UP ROOF E]LICENE
AS SHINGLE
WOOD SHAKES
—C/o
NUMBER6 .Z Z 7 � /
LICENSED CONTRACTORS DECLARATION
hereby that em licensed urger erosions of Chapter B col tion
leon licerhas Is in
7000) of Division 3 0l the Business end Professions Code, anti my license le In full lone ark
form
°"°`
',
/
Z—L 7 /,
WOOD SHINGLES
License Clew uc. Number
` Z
(SPECIFY) / ❑
Dam ConnectorOTHER
OWNER -BUILDER DECLARATION
1 hereby aKlnn that I em. exempt from the Contaci License Lew for the following reason.
PROPOSED
(Sec. 7031.5, Business ano Professions Cade: Any dry or county whioh requires a permit to
caratma, eller, Irtprove, demolleh, or repair arty structure, rlor W Its Issuance, also requires M°
Pa
BUILT-UP ROOF Clapplicant
for such permit to lib a signed statement that he licensed pursuant to the provklons
of the Contractors I -cense Lew (Chapter g (commendng with Section 7000) of OMalon 3 of the
Business and Professions Code) at he le exempt Therefrom and the basis for the alleged
«th
rn /
ASPHALT SHINGLES Yd'
exemption. Any violation of Seaton 7031.5 by arty applicant for a permit subject° the applicant M
e cEll penalty of not then floe dollyees
aro
er y employees with r mom compess
❑ , as rte amp oyeaered wages as
wage:
nd the structure I not i s-❑
the work, anti the structure le not Intended or for sale (Sec. A, Business end Prose -
(Sec. and Profes-
sions s not gens own of property who bed t or
alone Code: The Contactors esUcensesuch Lew dome not rapplytrough
thereon, ark who does each work himsaft or through hie own ebulkin eor
InstI'.assn
I'"'Improves
are not ed th offered for kale. ll, however, the bulking improvtl
Impronone
ye ving Marement
One ye rKleti
ownerbulker will have the burden of pmvinp that he ddnot
F;7ION
notIs
bu ld or I forpurpose ofn, la.
bulltl ar Improve for purpose of ealaJ.',]I,
m owrror of the property, am exclusNaly contracting with licensed contractors to construct
the protea (Sec. 7044, Business end Professions Code: The Connhcrors Ucense Law does rot
T NO.
apply to an owner of property who bulla° or Improves thereon, ark who contracts for such protects
-with
a contact«(a) Mutase pursuant to the Contractors Ucene° I-aw.LA-TION
� I em exempt under Sac. 8 P. C. for this reason
SPECS.
,B
owner Da1e
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
--s
I hereby allirm under Penalty of pedury One of the following dmaerstlor,
❑ 1 nava and will maintain a Certificate of Convent to setiandkre for Workers Comperaetfon,
Building L -o 7
es provided for by Section 3700 of Ne Labor Code, for the performance of I work for which this
Permit
m d
Seismic
hweaea'$S,
Workers f the work
❑ have and will the performance I which this p required by Section 37ke 0l
the Lobar Code, for the p ne of tyro work for which this permit le Issued. My Workers
2 Q 8
eater
Compensation Inaurente cantor end Polity number are:
Total s
Carrier 1--eG(Oa,�vC_ Polley Na�!�Z0Z-Q��S
PERMIT AUTHORIZATION
DATE
CERTIFICATEOF EXEMPTION FROM WORKERS'
.(
COMPENSATION INSURANCE N.C.E]
(This section need not be completed If the Is for one hundred dollars ($100) or leas.)
permit
U A T ob
V Ll -a
I carthy that In the performance of the work for which this permit is Issued, I shell not SmWo0yy
any person In any manner was to became subject to the Workers' Compensation Laws of Celh
All roofs shall be inspected prior to any rooting material being
forma.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
t� o aueANT: saPodeof Imptbn�u°ho
Applicant understands and will comply with all non point
�ttheWorkCe^�sheLa���t�whihco�
with such provalons or INS permit efall be manned reioked.
Source regulations.
I certlty that I have read this application and state Nal the above Inlurmetbn is corrac - I agree
to comply with all city end county ordinances and Mete laws reeding to bulking construction, and
All roof Coverings to be class 'C"or beffer.
hereby authorize representatives at this city to anis/ upon Ne above-mentioned property /or In-
s , 1
spai purposes
L__
(We) spree to save, Indemnify and keep harmless the City of Cupertino against IIab1181es,
judgments, costa and expenses which may In any way accrue against said _y in.sequence
IG TURE OF APPLICANT DATE
of iM ganune of tate permL
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