R-6546 I
PERMrr R_ 6546
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERM LPIRAn
REROOF PERMIT (408)777-3228 PERMITEXPIRES.IFWORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
' 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
ll.n-�1� q 59 RESIDENTIAL COMMERCIAL � OTHER
OWNER'S �. - ' HAZARDOUS FIRE AREA
NAME/V lA�.�' �C / i(_.� � YES ❑ —I undB Is andruff od a Class A
'�• NO ❑ aa�mbN. Initial I:C.B.O.:f
DRESS �]
If 50Z r4� �I( � EXISTING ROOF COVERING
AD
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESSn nn �;E i /' - _TYPE OF ROOF COVERING
EXISTING
PHONE � LJ BUILT-UP ROOF ❑
LICENSE -
IN BER !i ASPHALT SHINGLES ❑
- LICENSED CONTRACTORS DECORATION
I hereby affirm mel I am licaneatl under provislone of Chapter B(commencing with Section WOOD SHAKES ❑
7000)of Divadon 3 of the Business aM Professions Code,a d my license Is In full force and
affect.
�Tl/( WOOD SHINGLES ❑
Lkensa Clues uc.Number�J''� lr
Deb contracto OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
1 hereby affirm that I em exempt from the Contractors License Law for the buoying real .
(Sec.7031.5,Business and Professions Code: Any dry or county which requires a permit to
1" c«stmd,after,Improve,derrlolah,or repair any structure,prior to tin leeuance,also req rostra BUILT-UP ROOF ❑
awlk:ant for such permit to file a signed Statement that he Is licensed pursuant to the P stone
of the Contractors Ucanse Lew(Chapter B(commencing with Secdon 7000)of Dlvlslon 1 the
Business and Professions Code or met he is exempt therefrom and the b r the ASPHALT SHINGLES ❑
exemption.Any vlaletlon of Section 7031.5 by anry applicant ter a perl tub 4th lean o'
-�� a dull Penally of not more than five hundred dollars(5500).):
❑I,as owner of the property,or my employees with wages as their Sole cam tion, II do WOOD SHAKES ❑
the work,end me etrudure Is not Intended or offered for Gala(Sec.7044,Busln an,
Proles-
ebnsCMe:TheCanttactorsLJcerseLewdovenotappy�oanowner roperty bWltle« WOOD SHINGLES ❑
Irrprovee thereon,antl who does e- n work hlmeeH or t ph his own a oyeee,provltlM that 1
each Improvement«e rwt Inter or oHeretl br eels. r,the but Ing or Improvement \ 1
Is sola wnhbanaywr of compled ,the owner-bulbar veil f pro>Irg that he aid OTHER (SPECIFY)
`t Ile
not bulla or Improve for purpose 1 Bale.). ( ' '/
onstruct
tha0projeecct sec.� 7044 Basi and Fiche lions tr erne recttoore�iicen «Diabw does not PROVIDEI.C.B.O.REPORT NO.
apply to an owner of property o builds or mend hocomrecls for such projects
with a contrectons)licensed resent to the Contractor' nee Law. '
❑I em exempt-Mer S ,B 8 P.C.for thle reason PROVIDE MFGR.INSTALLATION SPECS.
Owrror D°I° APPLICATION DATE VALUATION PERMIT FEE
RKER' PENSATION DECLARATION
hereby eHlrm untler of 'ury ono of the following dederetbn: - q//y�
❑I neve erM will mebha a Icete of Consent to selfdneure f«Workare Compensatlon, Bulldln 2-^`
as proNtletl for by Sedlon 3]00 oft Code,for the performance of the work for whfchvele ^�l . fgL
permit blssuM. ! 4 seismic 2" ,�
ryry�d''hheve
and will the performance
Woanc e f neetlon Ineuroncis as required by d.My 3700 0)
ir�Lebor CMS,for the pedormente of me work for whkh this permit he leased.My Workers Q
Compersatbn Insur:T;;
a tartlet aM Polley number pre: Total l S o
Cenl f,*A, ����T Paley c �� ��Z PERMIT AUTHORIZATION DATE -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O `y ^
'(This section need not be completed It the permit H f«one humored dollars(5100)«ass.) -
I certlty Met In the performance of the work for which this permit Is lasued,1 shell not empty
ern person In any manner w as to eacome sublet, the WorFeii cortpansatwn of call- All roofs shall be inspected prior to any roofing material being
romla'G / �q installed. If a roof is installed without first obtaining an
~ Date ✓� , ` Applicant /!i� 2 i// inspection,I agree to remove all new materials for inspection.
NOTICE TO APPUCAM: If,after making this Carellcata of Exemption,you s1anM become Applicant understands and will comply with all non point
w°�fth such to plroviela�ne or mMis p rmlt shell bedoomed revoked r Code,you must roMwHh wmpN source regulations. p y - p
I certify met I ham read this application and state that the above Information Is correct I agree
to comply with all city and county ordlrorcea and state levee rekting to bulUng cunslruclbn,oM All r00 coverings to b0 Cla o�beIf
hereby authorize representatives of this city to enter upon the above-menikrnetl property for In.
sp lWal Purposes. /.
(Wal agree to save,Intlamnity en0 keep harmless the Clry of Cupertino against IIeMIWee, L
of Me gnte.costo eM expeneae whkh very In any waY accrue against ealtl City In consequerxro
ofd nts,cgetthis anclp«miL GNATURE 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