R-6428 APPLICATION FOR CITY of cuPERTINo
NUMBER PERMIT
R- 6 4 2 8
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)'777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1W DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS JO / / -
(// ��� 'G• RESIDENTIAL v/ COMMERCIAL OTHER
-
OWNER'S
/� /'/ J - -HAZARDOUS FIRE A
NAME .SI/Y L7 / �r-�T LAM l (�/ CT NO �IfyyMeims i-�is�u� Class A .
[fes Initial I.C.B.O.11
ADDRESS ! /a L— YlLL� / � • EXISTING ROOF COVERING -
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
��[ O/ 1 �/lU'� ryTO BE REMOVED TO BE RETAINED
NAME S
ADDRESS ��-C�' TYPE OF ROOF COVERING
clrY a zll 5' -� / Low
EXISTING
PHONE S3 6 S-2i7 _ BUILT-UP ROOFLICENSE
' ❑
NUMBER ZJ� ASPHALT SHINGLES ❑
• UCENSED CONTRACTORS DECLARATION
I hereby aNlrm that I am Iloonsed under provisions ol Chapter 0(commencing with Section WOOD SHAKES
7000)N DMsion 3 of the Business and Professions Code,end my license Is M LW force and
°lien. WOOD SHINGUSK ❑
Ucertee Cleve f Lk.Number 7/,e-3
Z Z rr(/ �7� Con tar OTHER(SPECT E]Date
OWNER-BUILDER RA*N PROPOSED
hereby eliBu me[ am exempt from Co Comma License Law for the following a rrnt to
(Sec.construct,
it Business and Profepiste,or re it any Any dry or county which requires a permit to
conetrun,alter,Improve,tlfile a s,or structure,Mat he prior to Nelseuarper alsorequiresprothsihe BUILT-UP ROOF ❑
applicant for such permite file aChapt r9(coemmet he is hceroetl Wrouenf tome pro Of
of the Coning Pro License Law(Chaplet B(commencing with Section]000)of Division 3 01 gee
Businessolid entl vlpa kxo of Cede) 7 met he W exempt antfor
or a end mu bade rot the elan to ASPHALT SHINGLES
a dyll Pen Anyf not mom
fhan ion Mai
byany applk:ant bra permit subjects me applicant to
e dull penalty of not more leen gor hundred dollars(h"ga �0D [�.`� -ES � ❑
❑Irks Ownerofstheproper not Intryded or offered for
"gas as Moir sole compessawl will do
Me work,entl the onrclure Is not Intended or offered for yale(Sec.]066,Business vtd Pefea-
Impr Code:The.an whoretissueLawtli snot appytoenownerofpropertywhoWBdaor OD 1u 99 ❑
Improves oiante,entl who doen etwm w offered
sag ole.It. ph his own employees,r provided met
ouchd within
entame are notIntendedcompletion,
leth altered M sale.If,Irowethe the ern of pr or Improvement r '
Is nt buildolnoneyeeoof r purosetion,theowner-builderwill have the When of provirp that he did TH R• PECI ❑
not build or Improve for purpose of sale.).
[3 1,as,owner of the property,em excluelvaly contractin with licensed controcmrs to construct
the protect(Sec.7046,Business and Professkxxs Code:The Contractors License Lew dee°tet PROVIDE I.C.B.O.REPORT O.
appy to an owner of property who W4de or Improves thereon,aril wits conmacla for such prolene Cy
wIm a contractors)Ilcenaee purauam to the Contractors License law. PROVIDE MFGR, INSTALLATION SPECS.
❑1 em exempt under Sec. ,B 6 P.C.for cols reason
owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one W the follveing declension: g/�
and will malwasin a Cert lIcato of Cansem to seddrwire for Worker$Compensation, Building/37
rovktnd fpr by Semen 37W of me Labor Cade,for Me performance of the work for which this � /,'�
perEl mit Is Issued. 7 �7 Seismic 76I hava and w111 malmem Workers Compensation Insurance,u repaired by Section 3700 of / !�
the Lobar Code,for the petlormence of the work for which this permit is issued.My Workers
Compensation Insurance carrier end Polloy number are Total 0
Centers �%[l/✓Y� Policy No.� 76� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N CC
(This section rend rot be completed N the porn it Is for one hundred dollars($100)or Ruse.), 7 7
I certify that N the performance of the work br vfikh this Permit Is Issued.I shall not
any person In any mariner so as to become subject Workers;compensci o calk All roofs shall be inspected prior to any roofing Material being
torrid. q installed. If a root is installed without first obtaining an
Date 2 � / AW1 cant inspection,I agree to remove all new materials for inspection.
eult,W7to MewoAM1 reCCo pensetlonninnME this.1ubecame
tlOL or o=myyu`ntus IormM1thcompy Applicant understands and will comply with all non point
wllh such provlelons or this permit shall be de it r source regulations.
t curtly that I have read this appllcallon and eta t the above Inlurrnmbn s correct.l agree
to comely with at dry end county ordinances and elate laws remmtg to building construction.and All roof coverings to be class" or better.
hereby euhorlze representatives of this city to solar upon the aboa rnentlonwd property for M.
spechon purposes.
(We)agree to wave,Indemnity and keep hermess the City of Cupertino against luebltitiee,
judgments,costa entl expanses which may In any way accrue against and CIry In consepuence
of me granting of this 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
OFFICE COPY