R-6637 PERMIT
APPLICATION FOR CITY of CUPERTINO , NUMBERR_ 6637
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(406)777-3'222 B PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS /J 1
O 21..>LL L.J . C,Ls- �"L i✓m RESIDENTIAL V COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA
YES ❑ II yes—I unOarstand that a Class A
NAME �//�/�/6 — —�-�0O .V BSL root assembly is required.
NO L] Irtbal
ADDRESS EXISTING ROOF COVERING
PHONE
.2 r^ 7 _O 9 NUMBER OF EXISTING COVERINGS Z
CONTRACTOR'S
TO BE REMOVED !::� TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING.
CITY a ZIP
EXISTING
PHONE - BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLE ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with SmI on WOOD SHAKES
7000)of Divialon 3 of the Business and Professions Code,and my license Is In full force and
effect.
WOOD SHINGLES ////
Dcenee Close Dc.Number KO//s,
DateOWNER-BUILDER
or OTHER(SPECIFY) �`
OWNom the OER DECL LicensN PROPOSED D �
hereby embus that am exempt bras the Contraction or coup Lew ler the browing reason.
(Sac.7ct,alt Business and Profademolish,
or ro Code: Any dry pr county which requires a permit to D
construct,or suer,ch
Improve,to His signed suatornamtpur any that
Is livensor to Its Issuance,also requlree the BUILT-UP ROOF ❑
of Me Contractor's for etch pecen b Illi aChapt statement Net he Is I Sectio pursuant to the prow the U _
of mho ssLaM neo Lew(Chapter a Is ex a putt wIef Section 7000)01 for
3 0l lea p
exemption.
end Pro lotion f Code)or Mat he Is exempt therefrom and the bells for the scant to ASPHALT SHING ENO
a d 11 ion.Artyf not more
of h actlm 70,71.5 by any applicant for a permit subjects the applicant to
e dull pPg�o0ely of not more than five hundred dollen with
wage 8y
pYes and wner
structure
irtgormyempbyeaswlmor mi.eStheir Bale compensation,will tlo WOOD SHAKES
Me mark,entl the onxYura Is rpt,seMew or s mi for dab(Sac.7044,Buelneee and Prof"-
stoma rna cantreaore Licence Law does elft appy to his Own
prop"who Wilds or WOOD SHINGLES
Improved thenen,and mi does such work redden or through ole own empk ng or prpvbed that
such Improvements are rwm Intended or offered for Bale.If,however,the bulWlrg or Improvement /J�
Is sold within one year of completed,the owner-bulbar will have the burden of proving that he did OTHER(SPECIFY) e//iJA/oeCl' 04 '&'4,
not bulb or Improve for purpose o1 sale.). e
I,as owner of the property,am exclusively connecting with&ended contractors to construct
the project(Sec.7040,Burliness and Professions Code:The Contectces License Law does not PROVIDE I.C.B.O.REPORT NO.
appy to an owner of property who oullds or Improves thereon,and who contracts for such Projects
with a contranorld)licensed pursuant to the Contractors License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑I em exam t ur der Sec. ,B 8 P.C.for this reason
Own
/ - Date -L�WORK=R'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the Idlowing dedaretbn: . ` y
as providedforfor by Section 37UU of thel LaoorfC ea,wa ne perro'm`�of the work for which ,J Building 17
Permit is Issued. _ c'.// C) Seismic
❑I have aM wIll maimaln Worker's Compansadon Insurance,as requlred by Sectim 3700 of / / Q V
,the Labor Code,for the performance of me work for which thus permit IS Issued.My Workers 1 1 7 J iJ
Ccmpensatlon Insurance carrier and PWicy number are: Total
Carrier PalcyNo. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION IfthepINSURANCE t.0)o O vey
(Thud diction need not be completed If Imre permit Ie for one hundred Odlere(5100)or lees.) 2 /
eIntntan� as to� eforwhich thus krit Is Id'peenll ° o�any prsonanymneabeof cdauojia Workers G rundboLaws CI All roof:shall be inspected prior to any roofing material being
rwnb. installed. If a roof is installed without first obtaining an.
Date - Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,akar making thle Corticate of Exemption,you should becorre event understands and will comply subject to tae Workers'Comperuetbn pprcvlsku xre of the Labor Code,yoat Mthwith comply APP P Y with all non point
with such provisiora or this permut shal,N deemed rooked. source regulations.
I cenlly that I have mad this application and state that Ne above Information b correct.I agree
to comply with all dry and county ordinances ane state laws relating to building construction,am All f Coverings to be class 10Dr better.
hereby authorize representatives of this clty to enter upon the abovamendoned property for In-
spectlon purposes. -
(We)agree to save,Indemnify arb keep harmless the Gty of Cupertino egalnet IIabIIWes,
juopmento,costa and expenses which may in arty way earue against seW City In consequence /
of the grenung of mia perrnu. - SIGNATURE OF APPLICANT• ATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL: -
INSIR DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS-TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY