R-6349 APPLICATION FOR cITYOFcuPERTINo
NUMBER PERMIT
R-
6349
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
•2_2 G 'A C4 - -2_U c> - 2'LfeS 2_2— '4
Z Iv5(n 2ZGSFS RESIDENTIAL COMMERCIAL OTHER
OWNER'S KAZARIDOUS FIRE AREA
YES ❑ N yes-I understand Met a Class A '
NAME roof assernbly is required.
• NO ❑ Int I.C.B.O.N
ADDRESS EXISTING ROOF COVERING
PHONE _ NUMBER OF EXISTING COVERINGS
CONTRACTOR'S ``
NAME C�A\ TO BE REMOVED TO BE RETAINED
ADDRESS (� c h f TYPE OF ROOF COVERING
CITY&ZIP—wGSs Lp+ s�k EXISTING .
PHONE -- - Zer3 -_7C17-7 BUILT-UP ROOF
❑
LICENSE
NUMBER L -fGUC� ASP,ALT SHINGLES
LICENSED CONTRACTORS DECLARATION
Q\ El
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Sewell WOODSHAKES
7000)of Division 3 of the Budness and Pretria lona Code,and rtry license Is in full for 'end
effect. /
1-3 -�44o.a 9 \p�WOOD SHINGLE ❑
Ucertse Close Uc.Number
N C O OTHER(R�ECI ❑
Date ( Contractor /
ONTmER BUILDER DECLARATION
cense `\�J) vV P
hereby affirmu Mat am exempt tram the e: Any
or county
Lew,for rite I rig raaepn. /
(Sec.7031.5,Business and Prolessbns Code: A+ry dty or county which requires•a�pprm I to
construct,alter,improve,demolish,or repair any structure,prior to Its ls.uanoe,.1.regj;Me BUILT UP ROOF /
applicant for such permit to file a signed statement Mat he is licensed pursuant to the p iony/
of Me Contractors Ucense Lew(Chapter a(commencing with Section 7000)of DlWebn 3 o�Md/
Buflness and Professions Cedrd or that he is exempt therefrom arot Me heels for be allepetl ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for o permit aubjacts the applicant to
a civil penalty of not more Mart five hundred dollars
❑1,as owner of the property,or my employees with wages as their sale compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profas-
slom Code:The Contractors License law,does not apply,to an owner of property who builds or WOOD SHINGLESElImproves thereon,antl who clean ouch work hlmsall or through his awn employees,provided!Mat
such Improvements are not intended or offered for safe.If,however,the Whding or Improvement
Is sold within one year of completion,Me owner-builder will have the burden of proving Mat he did OTHER (SPECIFY) ❑
not build or Improve for purpose of eels.).
❑I,as owner of Me property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Profeselons Code:The Contractor's Ucerea Lew does nal PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property wfxi Wilds or Improves thereon,w<1 who contracts for such projects
MM a cantractods)licensed pursuant to Me Contractors Ucense law. PROVIDE MFGR. INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the foliowing declaration: (�
❑I hexa and!will will maintain a Cedlfof Consent to self4rdsure for WorkaYs Compensation, BUIIdinj &
as provided for by Section 37W of the labor Code,for the performance of the work for which title '5,,?yin
permit Ls head. - Seismic 3,.1'D
❑ have and x111 maintain Workers Compensation Insurance,as requiredsu Section Worker's 0l )
the Labor Code,for the performance of the work for which this Wrtnit b Issued.My Workers Tots? Y
-Compensetlon Ineumnce rarder antl Policy number ere: �w L
Carder jtl i Policy No. 'cl10`bcYC� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be complete l If the Permit 1e for one hundred dollars($100)or lees.)
I cartity that In Me performance of Me work for which this Permit Is Issued,I shall not employ
any person In any manner so as to became subject to the Workers'Compensation Laws of Ceti- All roofs shall be Inspected prior to any roofing material being
fomla. installed. If a roof is installed without first obtaining an
Oats Applicant inspection,I agree to remove all new materials for inspection.
subject too the o��C� ense6ormak�e�of the LLa�mCE�myou must forthwith become Applicant-understands and will comply with all non point
with such provisions or this permit shaIgW deal revoked. you must fodhwlM comply source regulations.
I cer-ity that I have read this application and state Mat the above Information Is correct.)agree �}g��
to campy with all city and county ordinances and state laws releurq to Wilding conetnxtlon,and All roof coven 8 Class or better.
hereby authorize representatives of this city to enter upon the above-mentioned property,for In.
spectlan purposes.
(We)agree to save, Indemnity and keep harmless the City of Cupertino against Ilebllltlen,
judgments,cents and expenses whltlt may In airy way accrue against said City in caneequertco
of the warning orchis parmit. SIGNATURE OF APPLI DATE
PRE-INSPECTION: - PLYWOOD: IN-PROG SS:
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