R-6500 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R"
• INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
'
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING4 DRES 04G LO y�O M lkrlVl�, RES -
IDENTIAL, COMMERCIAL OTHER
OWNER'S AN d KALA
M HAZARDOUS FIRE AREA
AME M i f l W11 5, kr.Y KU NI� VES E] n yes— urtderrequired.metclan A
N
7f esBemby is ruired..
NO ❑ Inihel LC.B.O.A
ADDRESS-`4J� ^� L-U2S�j GSM �R 1V� • ( 'TI.11�10 EXISTING ROOF COVERING.
f�
PHONE 10�-- 2q2 ' Q3 I NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S
ry L Ro xy-I N(� TO BE REMOVED I TO BE RETAINED
NAME L 1/� ll� l,l /'
ADDRESS In C( // )�LA P�s.�f �,05 GIA'N5. /,� FISTING TYPE FR VE
CITY a ZIP o �( Y p nlh �6
PHONE `� BUILT-UP ROOF
LICENSE Z�
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑
]000)of DMe{on 3 of me Bualneee and Professions Code,and my license I°In full forte and
ellect. �� q
—7 2q l9 WOOD SHINGLES ❑
License CleeeLb.Number -1
Date �— 3l Contractor R l� � or-irlL( OTHER(SPECIFY) ❑
CMER43UIMER DECLARATION PROPOSED
I hereby affirm chat I am exempt frtrn the Contractors License Law for the following reason.
(Sec.7031.5,Business and Professions Cade: Any city or county which requires a permit to n
construct,altar,Improve,demolish,or repair any stnwture;prior to Its nuance,also require!the BUILT-UP R(
applkant for such penult to file a signed statement that he Is licensed pursuant to the provlelons 1 II)
of the Contractors License Lax(Chapter a(commencing with Section 9000)of DMalon 3 of the A n O D
'
Business and Professions Cade)or met he Is exempt therefrom and the basal for the alleged ASPHALTS GLrES'` 3 1"Q �L,I
exemption.Any vblelion of Section 7031.5 by any applicant for a permit subjects the applicant to LJ
e cMl Penalty of not more than Aye hundred dollars($500).): WOOD SHA S
❑I,as owsrer of the property,or my employees with wages as their sale compensation,will do ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profits- B
alone Cade:The Contractors License law don fiat apply to an owner of property who builds or WOOD SHI
Improves thereon,entl who caes such work Nrtmelf or through his own empto9es, roddad that
such Improvements are not Intended or offerad for sale.If,however,the building or Pmprovement
is sold within one year of completion,the owner-wilder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑1,as owner of the property,am"cluelvely contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors uce se Lew does rot PROVIDE I.C.B.O.REPORT NO.
apply to an owner of propery who wilds or Improves thereon,anal who connects for such pojecie
with a convector(!)Ikenaad pursuant to the Contractors License Lew.
❑1 am exempt under Sec. ,B&P.C.for this reason PROVIDE MFGR.INSTALLATION SPECS.
owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following dedaralicn:
❑I have and will maintain a Certificate of Consent to n[Hrwure for Warkere Compensation, Building
as proMded for by Section 3700 of the Labor Cade,for the penonmencs of the work for which this
Xie leaaea. Iq14- Seismic ��
11 have antl vhg maintain Workers Camperealen Insureroe,sa requlratl M Section 3]00 of
r Code,for the penarmaroe of the work for which this permh is issued.My Workers / O
Compen�sjation Insurance c.ard^er-end Policy number era: (� �� ���(' Totally
oc
Cardr t I'�A�yl
ML
Policy No./1 I OY LL!D PERMIT AUTHORIZATION DATE
CE KATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section nee!not be completed If the permit Is?of one hundred dollars($100)or lees.) -(/ l]r✓) � 7 7
I certly,that in the performance of the work for which this permit is Issued,I shall not"T
any person In any manner so as to became subject to the Workers'Compensedon Laws of Call All roofs shall be inspected prior to any roofing material being
fomia. installed. If a roof is Installed without first obtaining an
Date AppBoent inspection,I agree to remove all new materials for inspection. -
subiecctttoEhrow«lkre'Ccirwlnsailonproyial«�o°i eI-alCoicate de yYouM stfo°nmlth�ply- Applicant understands and will comply with all non point
with such proylslons or this permit shall ba deemed rel source regulations.
I certify met I have react this appllcalon and slate that the above information Is correct.I agree
tocompy with all clry and county ordneroes antl trate laws relating to wlk8rgconetrvctlon,aJS1GrN0ATUR.
ll of overm s be class" or better.
hereby authorize representatives of this dry to enter upon Ore eooe-mentbnetl proper r In 1 I� �
here yn Purposes. Iylll
(We)agree to save,indemnify and keep hernleea the Clry of Cupertino!gal Ilebllltlee,
Ju menta,conte this expenses which may In anyway accrue against sab Clry Inc uonsso onceOFAPPLICANT DATEal iBe grentin of this permit. �
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•COPY