R-6341 APPLICATION FOR CITY OF CUPERTINo
NUMBER PERMIT
R- 41L]
INSPECTION DIVISION P MIT PIRAn
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WOW IS Ni STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS ,']
100 3 a v(\�C L I I G ` t- V �• RESIDENTIAL-2LCOMMERCIAL OTHER
OWNERS � 7 HAZARDOUS FIRE AREA
�10 it T-la /. YES ❑ Il yes-I uWerstand that a Class A
NAME 11�� `/ roof essealbly Is required.
c NO ❑ Inffbal I.C.B.O.N
ADDRESS J a M I- EXISTING ROOF COVERING
PHONE
4,Ll icj `-r— 4153 NUMBER OF EXISTING COVERINGS /CONTRACTOR'S ?OO /' 31=1�—n
L-V - .
NAME
A� TN` TO BE REMOVED TO BE RETAINED
ADDRESS 2 4 6 �7. �(�— TYPE OF ROOF COVERING
N
CIBZIP EXISTING
PHONE 'rt BUILT-UP ROOF ❑
LICENSE
MUMMER IS-3/� /� ASPHALT SHINGLES ElLICENSED CONTRACTORS DECLARATION
hereby affirm mat I em si licensed under Professors
a1 Chapter B license
In with Sectonand WOOD SHAKES -
7000)of Division 3 0l the Business entl Probselone Cade,and myllcanse la In lull force entl
effect.
39 ClS3 WOOD SHINGLES ❑/�
Close Llc.Number
Date .
Date 9 contractor n Q OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm Chet I am exempt from the Convectors License Law for the foliclrg ro
waeon.
(Sec.7031.5,Business end Proteealone Cotle: Any city or couny,which requires a permff to
construct,alter,improve,demdtsh,or repair am strucwre,prior to its Issuance,also requires the BUILT-UP ROOF Elapp!=for such permit to his a signed statement that he Is licensed pursuant to the provisions
of the Ocntractors License Law(Chapter B(comrdendrg with Section 7000)of DNklon 3 of the• 0
exemption.Anyvalatkn of Sectlon pe
7031.5 by any apdicent for a rmh subjects Me applicant to C
e civil penalty of not more than five hundred dollars($500).): xpill-
0
h-�
❑I,as ovmerof the property,or my employees with wages as Meir ode compensation,will do WOOD SHAKES
the work,and me structure Is not Intendetl or offered for Bele(Sec.7044,Business end Profee- To n
stone Code:The Contractors License Lew does not apply to an owner of property who bullds or WOOD SHINGLES ❑ L�
improves thereon,and who dose such work himself or through hb own employees,provided that
such inprovemsnts are not Intended or adered tor este.ft,however,the Wilding or Improvement
Is add within one year of completion,the owner-bulkier will neve the burden of proving that he did OTHER(SPECIFY)
not build or Improve for purpose a eelclu -
❑I,eeowner of the propmry,amexclusa cenime:TIwnhntrace0s License Law
construct
the prded(Sac.70e4,Business entlsor deprvCoda:Toe add!who contracts
for
Law doesnot PROVIDE I.C.B.O.REPORT NO.
apply toinOwner of property who pulite tImprovesthereon,end who conuern brsuch prolecq
with a c am
licensed pursuant to the Contractors ucenm law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B$P.C.far this reenm
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKERS COMPENSATION DECLARATION
I her&ry¢farm under penalty of perjury one of Me following declair n:
as providedforforr by ISauabnk37DO Certificate
thebLabioorlCodeeBor to performance Worker's Compensation,for°which ale Building /V
de pN k Issued.
X have end will maintain Worker's Compensation Insurence, reSeismic
required by Section 3700 of /�I D '` \ c.1J
the Labor Cade,for the rformence of the work for which this rmlt s issued,M Workers v o /�
Compensation Insurance carrier and Pocky number are: /, Total / `�+ —
Carder`ST/4-TE FUAj4) . PoikYNoy/o(oC -51/ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C[]
(This rection need hot be completed If the permit Is for one hundred dollars($100)or lees.)
I certify Met In the performance of Me work for which this permit Is issued,I shell not employ
any person In any manner so as to become subject to the WorkersCompensabon Lews of Call- All roofs shall be inspe gii td 8n fool ;IF aLej Bing
bmle. installed. If a roof is tolled an
Date Applicant inspection,I agree to r Ve (�� ate Ition.
NOTICE TO APPLICANT: If,after making Mie Certificate of Ennnptbn,you should become Applicant Uflderstan I d WI�(Q(g Ql 117 i Dint
eubled to the Workers'Compenealbn IiroNelone of the Labor Cade,you must forthwith comply K1Y
with such provisions or this permit shel0he deemed revoked. - source regUlatloOS. ji Ai f1 p zv
I comity Met I have read this application and elate Met the above Informed"Is correct.!agree I' I1 r J O v,�99
to comply with all city and county ordinances and state laws relating to bulkiing conetmMm,snd All Covering
hereby authorize representatives of this city to enter upon the above-mentioned property,for In- $(}j'p I r JJJ ((�1c�
wectlon purposes. � J, `.0/.�_'�/,A� -
(We)agree to save,Intlemnly and keep harmless the City of Cupertino against Ilablllties. (0 l�i/N/-N=_-"L
Iudperonts,costs and expenses whldr may In any way accrue epalnst said!Gty In caruequenca SIGNATURE OF APPLICANT
of the granting of this parent.
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