R-6683 APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMIT
R- 6683
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.
BUILDING ADDRESS
1,011.1 qAfA 4kAA h
ill RESIDENTIAL COMMERCIAL OTHER
OWNER'S/� p' HAZARDOUS FIRE AREA
TIO W •'S 'KAWA {1OOI�r VES ❑ H yes-I understand that a Class A
NAME roof assembly is required -
n /� /� NO ❑ Infbal I.C.B.O.s
ADDRESS I"�F1,/_ I SLAV_,rA CLARA Aw1 l•N�P. EXISTING ROOF COVERING p
PHONE- _{y/p- � / 1 - O i / NUMBER OF EXISTING COVERINGS
CONTRACTORS�IOr�
NAME' ' 1 I`OV 1 I TO BE REMOVED 2— TO BE RETAINED
ADDRESS �( A, 1 / TYPE OF ROOF COVERING
CITYaZIP 1011 �AKu11�n '�} L. 1_690�0
EXISTING
Al_ 925- q11%
PHONE, BUILT-UP ROOF ❑
LICENSE �/2
NUMBER ASPHALT SHINGLES (
/
LICENSED CONTRACTORS DECLARATION
7")of Divi Division 3hoflI am licensed the Business and Pro eeebrre Code,r proviaons of end my(Ifw license isIn �a� WAD SHAKES n
effect.
Lkenee Cta mbar
215 WOOD SHINGLE D
Data L I'll niroctor R PECI 'JUL 1
OV/NER .
hereby ,Bu that am exempt nom the Canironore License Law which
the uire,ap reason.
(Sec.7ct.alt Business and blM,abes Code: Any city or eounry which re,also a permit to B
canlicant oIsar,such
ssiorrepeatem structure,prior topelpursuantto requires asffe BUILT-UP ROOF
of he rot for ouch permit to La a signed statement that he Is licensedSetio pursuant to no pro of the _
of the ss annaro escalate Lew(Chapter h Is exia rcJ ref Seaport 7000)of for ionthe 3 0l tied
. exefoesr entl violatakne Coda) 7mat he Is shy applicant
nt for
and me sbasisubjects
for me alleges ASPHALT SHINGLES f75�Q' J
exemption.Airyf hot onohankn]undr byallys(S501ntforapermll eublecte the applicant to
e dull penalty of rot more then Ove hundred doPero(5500).):
C]1,as owner of the property,or my employees cape wages as melr We compeneabon,will do WOOD SHAKES ❑
the work,and me structure Is not Intended or offered for sale(Sea 7093,Dueness ark Profes-
sions Coe:The Contractor's License Law does not apply to an owner of property who Wide or WOOD SHINGLES
Improves thereon,and who con such work himself or through his awn employee,provided that ❑
such Improwmehae are not Intended w offered for safe.If,however,the of lltling or Improvement
U Bold within one year of conrple0on,the owner-bulker*if hew the burden of pricAng that he did OTHER(SPECIFY) ❑
not bulk or bnprow for purpose of sale.).
❑I,aeownerothepmp",,emerrcluefwlymnuedl with lkerubd connacton to conetruo
me prgact(Sec.Two,Bushl and Professions Code:�he Contractors License Low dose not PROVIDE I.C.B.O.REPORT NO.
ep io en aver of property who bullde or lnprowe thereon,and who comeoa for such prolects
wnh a contractors)licensed pursuant to the Contractors Ucari Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penelry of perjury chat of the following declaration:
[I '/��/ /my�
I hew end will maintain a Cand care of Consent to"it-insure for workers Compensation, Building
as provided for by Section 3700 o1 me Labor Code,for me performance of the work for which the �7Q �
permit is Yl issued. �I I� �1� l0• Seismic AJC
hew and will melmerf Workers f the work
for Insurance,a required by Section 3700 of
_uhdL�rns Code,for the performance of the work for which this permit Is Issued.My Workers l 112,
70
Caamperwatkn<Inaureenc�e carrbyr'erk Polley number an: /��`'Uld{O l�k � Total
Carrier -/T K' , AAN MICYNO. 7 TY PERMIT AUT ORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
- (Tell section neetl not be compbtetl ff me permn fs lar ane hurgre dollen(5100)a leas.) 7�� Z� I
I cel that it the performance of the work for which this permit is issued.I shelf net emp Icy
any person In any manner ec ea to became subject to me Worker' Laws of Ca II- All roof.,shall be inspected prior to any roofing material bein
torrid. installed. If a roof is installed without first obtaining an -
Dale 2 APpII inspection,I agree to remove all new materials for inspection.
NOTICETO ARPLIC If,aner a this CerlBkala Exempllon,you should oma Applicant understands and will con I with all non point
subject to the Workers' ry telae o the r Cade,you must forthwith comply ' A pP p y
with such pronakne or rub li I ahalim ad. source regulations.
I cart that I hew road this application and slate that me above Information Is rnrract.I e
to complywim all dty end county ordlire ices arM state laws relating to bulltl ng co a ru,d ,ark Il r I coverings class"C"or better.
hereby authorize repnaentatlwr of this dry to enter upon that ebovo-mentened pmpe for V
specron purposes. �1 n
(We)agree to saw,Indemnity alb keep harmless the City of Cupertino against I 411003, L L
ludpments,carts and expenses which may In ally way accrue spelno eek Ory In conseq
of me gri of this pehmil. S NATURE O APPLICANT ATE
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