R-6571E
IS
PERMIT
R 6571
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION ' PERMITEXPIRATTON
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.
BUILDING ADDRESS
21-3. / C •f'[/ .xP v 1i
RESIDENTIAL COMMERCIAL OTHER
OWNER'S -
HAZARDOUS FIRE AREA
'
A
YES ❑ It yes - I ulderstanclthat a Clens A
NAME .eO e^-. Ta=
roof assemby is reWired. '
NO ❑ Irtilfal I.C.B.O. B
EXISTING ROOF COVERING
ADDRESS
NUMBER OF EXISTING COVERINGS l �/ 6 N (y
PHONE !egg
CONTRACTOR'S
NAME L ✓ I •s, x:I 6 C' -L 4:,—f4:,—fTO
BE REMOVED 1L� TO BE RETAINED
ADDRESS
TYPE OF ROOF COVERING
ClTyazlP cf 4:r7i�I
G
Y S o 3 7
/
(*00
PHONE (* 00 % 7 4' Xe SM
UIL - P El
D
LICENSE
N
�QoQo
INI STS�N `Cb ❑
I.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provlalons of Chapter 8 (commencing with Section
WOOD SHAKES
. ]000) of Dhnsldn 3 of the Buelnass and Professions Code, arM my license Is In lull force and
sllect.
❑
9 6/� /7 F r
Uceam Gass Uc. Number
i ^ 2 �' /� ! 1 yr sI f-47 'e OV/
. OTHER (SPECIFY) ❑
Data Convector IC
/
OWNER -BUILDER DECLARATION
_
PROPOSED
1 hereby affirm that exempt from the y reason.
Lew for the foll7mews
(Sec. 7031.3, an e: Any city ap
ark or caun
Code: Airy dy or county which requires a permit to
after,1prBusiness
allsh,Professionsre, enyetthate, prior tialasuancweeuire. to
eh, oral
caneWct,orsuImprove, dernto
BUILT-UP ROOF ❑
stapair
file that he lith a purs,se,
Ilcom Wr00)o to the provisions
for such permit to Ills a Chapt
ofapplicant
Section
of the m; an dors Ucanae Lew (Chapter a (commencing wkh Section 7000) of Division 3 e the
r 9 (commencing
and Coda) or that he Is exanpt therefrom and the belle for the alleged
ASPHALT SHINGLES
wempeo
viclatelons
Any of Section h031,5 subjects me applicant to
of not moreIon
S500tbrepermk
a dyll Pen.
undred doany ors
e dull penalty of not more than Ihre hundred tloNere (5500).1: '
ads
WOOD SHAKES ❑
❑bas"nor of the property, or my empbyeee with wages as their compensation, willW
the work, ark Me structure Is not Intended or offered for sale (Sec. 70", Business ark Profes-
sions Code: The Contractors Ucanse Lew doff net apply to an owner of property who bI or
WOOD SHINGLES El
s own employees, provided
es thereon, and who does such work himelf or through Nd ro
Irrptovu
such Improvements we not Intended or offered for sale. ll, however, Me building or Improvement
Is sok within one year of compbdon, the owner -builder will have the burden of provirp that he did
OTHER (SPECIFY) ❑
not build or Improve for puryoae of sale.).
I, as owner of Me property, am mclushely contracting with licensed contractors to construct
the project (Sec. ION, Buelnase and Pmfosslons Code: The Contractors License Lew does not
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who bulks or Improves therean, and who contracts for each projects
witcontractor(s) licensed pursuant to the Contredoes❑care law.
PROVIDE MFGR. INSTALLATION SPECS.
1 em exempt unclear Sm. ,B 6 P. C. for this reeeon
Owner Jr/t r nDate fj ^_ Z �'•' O
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
-
•7
I hereby etfirm under penalty of perjury oro of the following declaration: -
❑ 1 here and will rrelaten a Cardficate of Consent to self -insure for Worker's Compensation,
a• for by Section 3700 Me Labor Code, for the forance the for which We
BuildingZ-
provided of performance of worn
astral is issued.
Seismic 8 Q
1 have and will maintain Workers Compensation Insurance, as required by Section 3700 of
the Labor Code, for the performaroe of the work for which Mie Permit Is leeum. My Workers
Comperuiatkn Irau anI carrier and Policy number are:
Total(/2-;7,9
Carrier acucy No.
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
r
COMPENSATION INSURANCE N,O{]'
.
(Thio section need not be completed X Ma permit in for ane hundred dollars ($100) or lees.)
I canny, that In the performance of the work for which this permit is Issued, I shell not employ
any person In any manner so as to become subject to the Workers' Compensation Lowe of Cali.
All roofs shall be inspected prior to any roofing material being
fornia.
installed. If a roof is Installed without first obtaining an
Dale �f- 2t-9 ' Applicant '4"k'� oo-r " ti'�na�.6
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It, after meklrp this Certificate of Exemption, you should became
Applicant understands and will comply with all non point
pP P Y P
suNeot to tM Workers' Compena rbon prmislons of the Labor Code, you must forthwith comply
win such provlaons or this Permit shat be tleemed revokad.
Source regulations.
I certify that l have reed this application ark state Met the above Information a comect. I agroa
to comply with ell city and county ordirencee and state laws relating to building construction, and!
All roof coverings to be class Or better.
hereby authorize repraaftantives of this dry to enter upon the abuve-montioned property, for In.
stamen purposes. -
(We) agree to save, Indemnity and keep harmless Me City of Cupertino agalnst facilities,
- r•f o t
k•/ �- �tirfl,✓�7 , S- 2 S-/�
l�dgmenfn, were and expenses which may In any way accrue egelnst veld City�a co113mil nca
permit -
Ifthe granting of is permit.
SIGNATURE OF APPLICANT DATE
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