R-6262 PERMIT R_ 6 2 6 2 .
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION.
REROOF PERMIT (408)777-3228 . PERMIT EXPIRES IF WORK IS NOT STARTED
_ - WITHIN 1W DAYS OF PERMIT ISSUANCE OR
1 W DAYS FROM LAST CALLED INSPECTION.
'
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL—OTHER—
OWNER'S
OMMERCIAL OTHEROWNER'S HAZARDOUS FIRE AREA
nYES ❑ It yes—I understand that a Class A "
NAME W 6 MAAL14AN21-V root aysemhty'rs required.
NO Initial I.C.B.O.If '
ADDRESS �t� EXISTING ROOF COVERING
_70 PHONE (O Z NUMBER OF EXISTING COVERINGS
CONTRACTORS
'/n,,
NAME Er.,.)AI ,SA try I`-•IIZ eIrO I N(� TO BE REMOVED TO BE RETAINED
ADDRESSTYPE OF ROOF COVERING
CITY&ZIP Z2�7. L\OCOI.,IJ AV 9- . �..�, q51_&5
EXISTING
PHONES —OLa� BUILT-UP ROOF ❑
• CENSE
NIUM13ER - ASPHALT H ES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter B(commencing with Section WOODS ES
7000)of DMsIm 3 of the Business and Profesabns Code.and my license Is In full force and
effect. p, �1 / WOOD SHIN .El56
Upon"Class ` Up.Number
Data, II' Contractor O1raAT�.SHru LF L�roFIT r'4 OTHER (SPE/CII`s1 ❑
OMER-BUILDER DECLARATION PROPOSED V/ '
I hereby affirm that I em exempt from the Coneectoes License Law for the following reason.
(Sac.7031.6,Business and Professions Code: Any city or county which requires a permit to
,munsuct.alter.ImPrm®,demolish,or repair any SCuvvre,plor to Its Issuance,also retulre,the BUILT-UP ROOF%y ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the prevr,brs
of rhe Contractor's License Law(Chapler I lcormianxdrq with Section 7000)of DMSbn 3 of Cie ❑
.� Business and Prohnitions Code)or Net he Is exempt Csrefrom and the beer,b the atlegee ASPHALT SHINGLEr?
exemption.Airy violation of Section 7031.5 by em applicant for a permit subjects the applicant to C
a cMl penalty of not more than fiye hundred dollars($500).):
01,as owner of the property,or my employees with wages as Noir able compensation,will do WOOD SHAKES ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Buelnem and Probes.
alone Code:The Contractor's License Lew does not apply to an owner of property who builds or WOODSHINGLES
Improves thereon,end who does aum work himself or through hie own emp"es,provided that El
Improvements are not Intended or offered for We.II,however,the building or Improvement
Is sold within one year of completion,the owner4pullder.111 have the burden of moving that he old OTHER(SPECIFY)
not build or Improve for purpose of sale.). Z
❑I,mownerofC property,emexdLW"ycontmcdwnh lkxneetl coniracton to coimvud 3SZ✓
the project(Sao 7044,Business aro Professions Cobalt,Contractors Ucense Lew close rob PROVIDE I.C.B.O.REPORT NO.
appy to an owner of property who builds lir Improves thereon,and who contracts for Such projects
with a coamctor(s)nceneed Wnuanl to the ConVedors License Law.
❑1 am exempt under Sec. ,B 5 P.C.for Ctls reason PROVIDE MFGR.INSTALLATION SPECS.
owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: •33
❑I have and will melnteln a Carillcete of Consent to Bell-Insure to Worker's Compersatlon, Building
as provided for by Socim 3700 of the Labor Code,for the performance of the work for which thr,
permit to Issued.
■1haveend will maintain Workers ConpenseUon Insurance,as requiretl by Section 3700 of (' Z— 1 ' U—"` SBISmIC ' D
ball
for the performance of the work for which I permit Is Isawd.My W rs / Q
Compensation Insurance carrier and Policy number are: / Tctal 1-6r' 9 O
Carrier_aFNV' EPA PcucyNo. �T4 3 . PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 T
(This section head not be completed If the permit r,for one hundred dollars(5100)or lata.) ( Imo^
1 tartly that In the performance of the work for which then permit Is Issued,I shell not employ
any person In any manner to at to become subject to the workers'ComFameetloo Laws of Call- All roofs shall be inspected.prlor to any roofing material being
f0R1fo installed. If a roof Is Installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOToDw�e�rweapiohis� LatExemption,
� you oMorne
tubjech ttherCoertbn provisions of Laboremast fowM co Applicant understands and will comply with all non point
wlth such prw lab or thr,penml shell be deemed revoked. Sour re Ulatlons.
I tensity Cat I have read this application aro state that the above information Is correct I agree
to comply with all dry and couty nordinances aro state lawn relating to twlkung corsmucuon,acrd .All f ve rings t 30 class"C"or better.
hereby authorize mpresentathree of this city to enter upon the abo�mentbned Property for In-
(We)agree to save,lndemniy and kay I harmless;the Cita against
Cupertino apaInst Ileblllllee,
of Me grte,cotta this expenses which may In arty way accrue against Sam Clty In caneequence S GNATURE OF APPLICANT DATE
of the granting of N: Permit r
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 -