R-62560
OFFICE COPY
PERMIT
R- 6256
APPLICATION FOR CITY of cuPERTwo NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
_ REROOF PERMIT " (4W)777-3228 - PERMIT EXPIRES IF WORK IS NOT STARTED
. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDINGADDRESS
-
`7
RESIDENTIAL— COMMERCIAL OTHER
OWNER'S -
-- HAZARDOUS FIRE AREA '
// )�.
YES ❑ If yes — Ia1dBrsl8fld Nat a Closer A
�
NAME V l / Y KA /
root eavem0ly is reglmetl.
NO ❑ In I.C.B.O. R
ADDRESS / U(
��7/�
EXISTING ROOF COVERING
O
/
pT�C�I�
//
PHONE JQ 3CQ Gd J L� •
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
_
NAME /
TO BE REMOVED TO BE RETAINED
--7 / q
�-
ADDRESS 3 .S /�2
IYPE OF ROOF COVERING
CITY d ZIP/ / y.,St
-
EXISTING
PHONIl 97/ r 71566
BUILT-UP ROOF
LICENSE .
NUMBER ZOI v
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B (commencing with Section
WOOD SHAKES ❑
7000) of Olvinon 3 of Rw Business and Prosselons Codnd
Coda, and my license le In full force a
effect.
�,',_3 �( ��^� /DA
WOOD SHINGLES E]
License Class LIc. NumEer
Date CI Contractor ✓ /C�CJ7�i'st
OTHER (SPECIFY) ElOWNER"BUILDER
DECLARATION
PROPOSED
hereby that I em exempt from Ne Contractor's License Lew for reason.
(Sec. , Su a end re uiresistloving
Cade: Any dry or county which requires e permit to
u0 , aft, , Improve, offalProfessionsorbei eny pricx tolicen till requires the
dero10Ink,
csrsapplicant
BUILT-UP ROOF
asindstaair
suImprove,
for each p mentructure.thatho
to fib a signed statement that he B Ikaneetl pursuant to the provisions
opo pursuant e
a Co
of Rha Contractors �en encing with Section ]0001 of Dlvleihe 3 of the
Law (Chapter a is
h is Ra
B.exemption.
and kii etla) or that exempt and bade he the staged
ex
ASPHALT SHINGLES ❑
voted n Of Sectionantforam
exemption. Artyf nor onof Sea ton trya^y applicant fora pemdt subjects the eppllcont to
hundred
• e dull penalty of trot more than five huntlred tldlers
I, the their do
D HAKES El
as owner of property, or my employees with wages in onto compensatlon, will
the work, end Rte structure Is not Intended or offered for sale (Sec. 7044, Buslnees and Profes-
alone Code: The Cmunifor's Ucenm Lew does not apply to an owner of property who Wilds Or
W GLES ❑
Improves thereon, and who does such work himself or through his own employees, provided that
such Improvements are not Intended or offered for sale. If, however, the Eullding or Improvement
Is sol wlMln one year of completion, the owner-GNder will have the burden of provlg that he did
OT '
not buil or Improve for purpose of aala.).
'Q1,
as owner ofthe property, em excurionty convectlrq with licensed contractors to cawRuctI�''II
Ne 7044, Budnas Professions Code: the Cmtractore
-
PROPORT NOeppN
project (Sec. and License Law does rot
to an owner of propery who bulldv or Improves thereon, and wow contracts for such projects
7MJAUE.
with a contracmrfs) licensed pursuant to Ne Contractors License Law.❑ I am exempt under Sec. B 8 P. C. b RRa reason
PROrTA4".$O ECS.
Owner Date
N DATE , VALUATIO
PERMIT FEE
ATIOAPPLICA
WORKER'S COMPENSATION DECLARATION
By
1
Building
I hereby affirm under penalty of perjury one of Ne following declaration:
ID I have and will mdnteln a Certificate of Consent to self -Insure for Workers Compensetln,
as provided for by Section 3700 of the Labor Goods, for the performance of the work for which this
permit is Issued.
�� �^
�WO
g
9a
�heve end will maintain Worker's Compensation Insurance, as required by Section 37DO of
Seismic
ih Coda, for the parfonnance of the work for which ihls permit Is Issued. My Workers
Compensation )IaIural number ere:
tamer antl
Total
rco IPolky
7B
�/6 �✓0.
PERMIT AUTHORIZATION
DATE
Carrier 41 Poucy No. •
" CERTIFICATE OF EXEMPTION FROM WORKERS'
77_
COMPENSATION INSURANCE NQ
(This section need rot be completed H the permit is for one hundred dollars (5100) or less.)
Tc)e /�N7rJ ^-�V CG:
I will that In the performance of the work for wNch Ihu; perml Is Issued, I shall not employ
any person In any manner so as to become subject to the Worl,ers' Compenaeaon taws of Call-
All roofs shall be inspected prior to any roofing material being
fornia"
installed. If a roof is installed without first obtaining an
Data Applicant
inspection, I agree to remove all new materials for inspection.
sub��to Bh wore APPLICANT:become
Compensation rrovisionls ofthelcate of Labor Code, must forthwith
p you must brihwith comply
Applicant understands and will comply with all non point
with such provisions or Mb permit shell be tleamed revoked.
,
source regUlatlODS.
'T
I certlty that I have read this applicatlon and state that the above Information Is correct I agree
to comply with at city end county ordinances and state laws relating to Wiltling construction, and
hereby authorize reprenimatives of this dry to enter upon Ne above-mentioned property for In-
All roof coverings to be,class "C' or better. '
I/
spectln purPosee.
(We) agree to save, Indemnify and keep harmless the City of Cupertino against liabilities, '
judgmecosts nts, cosands expenses which may In any way accrue against sold City.., consequence
of the gran)ng of Nle permit.
ATURE 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY