R-6505 PERMIT
APPLICATION FOR CITY EC I N DIMS No
NUMBER R- 6505
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT.ISSLIANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
0 ���I' I�EPPE� '1,
RESIDENTIAL COMMERCIAL OTHER
OWNER'SHAZARDOUS FIRE AREA
VES ❑ f yes—I understand that i CFresa A
NAME j / root assembly is required.
�w NO YJ Initial I.C.B.O.If
ADDRESS' EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOR' , I
/�{� TO BE REMOVED TO BE RETAINED
NAME -f•/- / �-'I N r'CiF/, r �J�
ADDRESS9 !� TYPE OF ROOF COVERING
CITY 8 ZIP d T
EXISTING
PHONE BUILT-UP ROOF ❑ .
LICENSE
NUMBER ASPHALT SHINGLES—
_
LICENSED CONTRACTORS DECORATION //,
hereby aft Chet I am I licensed under provisions of Chapter B(commencing with Section WOOD SHAKES D
]000)of OMelon 3 of the Business"Professors Code,"my license Is In full fore entl I I' I
effetl.
C - 1-1 WOOD SHINGLEIS�/ MAY 0 F51999
Ucense Clew Uc.Number _
Date S-�..A cono-edor OTHER(SPECIFY) ❑
ONNER-BUILDERD C ON PROPOSED
I areby affam exempt that I exempt from the Carltrectofe tcantse,Lew for the fofg reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to-
construct.alter.Improve,demollah,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he is licensee purfu rat to fire proval0m;
of the Contractors License Lew(Chapter a(commandnp with Section 7000)of Dlvislon 3 of the
• Business end Professions Code)or that he k exempt therefrom arW the bash for Me alleged ASPHALT SHINGLES /S-(
exemption.Any violation of Section 7031.5 by any applicant for a permit subfegta the applicant to
e dull penalty,of rot more then INe hundred dollen($500).):
❑L as owner of the property,or my employees with wagea as Mair sola compensadw,will do WOOD SHAKES ❑
the work,enc the structure is not Intended or offered for fele(Sec.7044,Bualnes,and Praha.
alone Code:The Contractors license Law Was not appy to an owner of property who builds« WOODSHINGLES
ov
Impres thereon,and who does such work himself or through his own employees,prwked Nat ❑
such Improvement,we not Intended or offered ler sale.If however,the bulking«Impro,emenl
Is sok within one year of compbdon,the«vner-builder ariu neve the burden of proving that he did OTHER(SPECIFY) ❑
not bulk or Improve lar purpose of sale.). .
I,m owner of the property,em exciusimly contracting with Ikensed contractors to construct
Me project(Sea.7044,Business and Professions Code:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bulks or Imprevea thereon,and who contracts M such projects
with a contractor(s)licensed pursuant to the Contractors Ucerwe Lew.
❑1 em exampl under Sec. ,B&P.C.M tics reason PROVIDE MFGR.INSTALLATION SPECS.
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: /
❑I have and will maintain a Cantlkata of Consent to seti4nsure for Workers Compensation, Building
as proWded for by Section 3700 of the Labor Code,ler the performance of the work for witch this
permit is Issued.
❑I have and will maintain Workers Compensefon Insurance,as required by Section 3700 of NNN ! / Seismic
-the Labor Code,for the performance of the work ler which this"Mit Is Issued.My Workers TOIeI /1 7 QO
Compenaacon Insurance canter and Policy number are:
Carrier - Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ - -
(This smticn need not be completed If the permit Is for one hundred ddllera($100)or lase.)
1 cera ty that In the performance d the wale farNi,permll Is Issued, shell not em icy
any penal in any manner so u to bec«ne ayy aygthe Workers'Compensation n Iof Vali- All roof^shall be inspected prior to any roofing material being
lents. installed. If a roof is installed without first obtaining an
Date s: Appnoant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPUCANT: if,after making thio eNOcate of Exem you should become A licant understands and will
sublect to the Workers'Compensation prvvbkns of the Labor Code, p
ust forthwith comly PP comply P y Wlth ell ❑On- point
with such pravhlons or this permit Mal0be deemed!reoked. Source r ulations.
I certlty that I have read this eppllcetlon and state tat the above Information Is correct I agree.
to comply with all city and county ordinances and state laws relating to building construction,arM ov ringst het s"C"or better.
hereby authorize reprseentetives of We city to enter upon the ato rnentionw property f«In-
spection purposes.
(WWee)agree to save,Indemndy and keep harmless the CIry of Cupertino against Ilabilllleq
,u the prereriun�d tyle peminieee which may In any way axrve egelnst said City In consequence I RE AP DATE
PRE-INSPECTION: PLYWOOD: IN- GRESS:
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 '