R-5584 1
APPLICATION FOR clTv of cuPERTwo
NUMBER PERMrr
R- 558
4
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (408)7n-3,223 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS IRE AREA
EPo r+,AL PIQ 7A FFo►9 .YES ❑ If ys5 ,I mbly Isf�ihal. Class A
NAM root s—l unci s Irad:
• '` L o No " lnffiW I.C.B.O.Y
AD � �t[ Sl� d14�1 ZSA) S4GtIS C�C[k lg1j/ EXISTING ROOF COVERING
• ADDRESS -
PHONE yob) 935- ?/6 D • NUMBER OF EXISTING COVERINGS 1
CONTRAC OR'S /�
NAMESQ[ LJrfi , 02 + Nr SYS,kmS TO BE REMOVED TO BE RETAINED
ADORESS�� . • T-YPF OF ROOF COVERING
Cmaz7 9� IQ[)Idi� 9SI/L EXISTING
PHONE('y ID$) J-71— 12 BUILT-UP ROOF
NUMBER ASPHALT SHINGLES ❑ -
LICENSED CONTRACTORS DECLARATION
I hereby edlrm that I em licensed under provisions of Chapter B(commencing wllh Section WOOD SHAKES ❑
70DIff of DMelon 3 of the Business and Profession,Code,end my license is In lull brae and
effect.
C_2j C_ ,Lp�O WO D INGLES ❑
Dcenee Clea q la Number _70 .
Date �Z—�' Ig Con" o O PECIFY) ❑
.OWNER-BUILDERDECLAP.ATICN PR E '
hereby 'Bu rhes I am exempt from the Code: Any cly orUcersecoup law for re uirfols a remit.
(Sec. uct, It r,Impr ve entl Profo,or reitanArty ate or county which re,also a permit to
applicant,alter,Improve,demolish,a n repair any structure,prior to a Issuance,also reponse the BUII q�Llp p
at tho rat for such penult to Ills a caned statement that, It licensed pursuant to the prov�aloro ,\r�Y�CrJv(L
of the ss,and
license Lew(Chaplet B(commencing wIM Section the basis sl for the ale the -
ex a ptIo end volatI loo f Code)pr that he le axampt antfora and the jts for the alleged A$P H L S ❑
axempPe n.My violation of Section hundred
by any dollars($50 ).for a Permit subjects the eppllrant to
e dull penalty a not more man Ids y empl ys" Ih wag): WOOD S
❑Ices owner tithe are Is not I tended oyeee wlM wages(as Sao
sole compensation,ron,w111 s- ❑
the swock Ca and Ma structure le not Intended Law don not for eels n ow er of Buelnaer entl Proles-
alone Code:The,a n whore as ouch Law don not apple to an owner of property who builds or WOOD SHINGLES _such
es thereon,entl who does deco workred for or .If,lhthrough his own employee,,provbod that �S
ouch Im within
am
year
are not Intended the
oymor for lair. ill lwweare he en of
or Improvement -
nsmid tbuildorimpteyeerrpurpoletoffueleowner Eullderwlll have the burdenof proNtgmethadb OTHER(SPECIFY) /r_ ❑� /
not build "Improv,ler purpose al eels,), a_7lL .
I]Lec Amer of the property,amexclufessions Cmctirq wlhlicrnaeoronimm Luo construct not
the aporgan(Sec.00aa,pertyee and Professions Cede:The Contrho contracts
fr Law does not PROVIDE LC.B.O.REP(�Ffi o.l
apply m contractions)
of property who W Inde or Improver tot's License
who contracts for each projects j-
wIMa c rn exempt)licensednrSao
pursuant to me contractor's License Lew. PROVIDE MFGR.INSTALLAI LQLI�I SP
❑ em exempt antler Sec. ,B 6 P.C.for this reeron I'-,L r
11
Owner Date APPLICATION DATE VALUATION "YOPERMIT FEE
WORKER'S COMPENSATION DECLARATION
- I hereby a18rm under penalty of penury one o1 the following declaration: '
❑1 have and w11I maintain a Certificate of Consent to self-Insure far Workers Compenretlon, Bu
as provided!for by Section 3700 of the Labor Cade,for the performance of the work for which this
permit is Issued. 00
❑I have and wW melnuon Workers Compensation Insurance,lie required by Section 3700 o1Q �1 $e mIIIC
Ow Labor Code,for the performance of the work for which Mie permit b issued.My WoM1<rs — I�� 1 L
Co notation Insurance carr4er entl Policy nc� r are: ( L Total
Carrla POI1cyNO...3 .1g73PERMIT AUTHORIZATION DATE
CERTIFICATE OF EX III
FROM WORKERS'
reCOMPENSATION INSURANCE N.CO _F'
") r/
(This rection need rwt be completed If Mon
e permit Is for e hundred dollen(S1 W)or foes.) (/"�
I candy that In the performance of the work for which this permit is Issued,I shell not empty
any person In any manner w lie to became subject to the Workers'Compenselbn Laws of Cali- All roots shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Data Applkanl inspection,I agreeQrove all new materials for inspection.
NOTICE TO APPLICANT: If,affter making MIs Confbate of Exemption,you should become q Ilcant underswill nom I with all non int
sublect to the WorkersCompeneatlon provisions of the Labor Code,you must forthwith compy PP P y PDwnh such pm alone or this permit all be deemed revoked. Source regulationI nerdy that I have read his application entl state that the above Information le coned.I agreeto comply Man atl city and county ordinances entl suite law,relating to building construction,entl Ir Of coveringss"C'Or better.
hereby authorin repremmall of this city to enter upon Me above-mendonad property for In.
reaction Purposes.
(We)agree to sous,Indemnity and keep harmless the City of Cupertino against Ilebllidee,
Judgments,coats,and expenses which may In any way accrue against Bald Clty In consexquerwe AT RE OF APP ICANT DATE
of he granting of this permn.
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 DOPY