R-6345 PERMIT R_
APPLICATION FOR CITY of CUPERTINo NUMBER 634
5
INSPECTION DIVISION PERMIT XPIRATION
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 -
"Z2
Q LAY, L_lA RESIDENTIAL COMMERCIAL - OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class A
NAME rod assembly,is required.
NO ❑ InRIBI LC.B.O.:1
ADDRESS EXISTING ROOF COVERING
PHONE - NUMBER OF EXISTING COVERINGS
CONTRACTOR'S,
�� TO BE REMOVED TO BE RETAINED
NAME t^.� �1�(�0eyL-z� VLO.'��(`�_ cz�_. -
ADDRESS ` TYPE OF ROOF COVERING -
CITY&ZIP tS —Ne> .
- EXISTING t
PHONE Ztpfie 2-4 -7P-7-7 BUILT-UP ROOF ❑.
LICENSE
NUMBER 1-1(4 p _ ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter B(commencing with Section WOODSHAKES
7000)of Division 3 of Me Business and Professlons Code,and my license Is In full force and
effect.
I1WOOD SHINGLES ❑
License Class �`•�� uc.Number f
Date li, 3 Contractor Llp1 - OTHER(SPECIFY)j
MeCoOWNER-BUILDER DECLARATION PROPOSED G�f
hereby affirm that em exempt from me Contractors License Law for the requires
a reason.
(Sec.]0.315,Business and Professionstop Cade: tAnyrue dry or county which req al ss a permit to
mrtsWct,eller,Improve,to filedemol[sift,signed
n repeat any structure,prior to IIs Issuance,also requires the BUILT UP ROOF
applicant for such permit to file a elgnod stateroom that,% 4l S tlD pursuant to the provisionsoth -
• of Me ss cmd Pro L sfons Lew(Chapter B(commenolnp with Sedlon Me al Division 3 of Me
Business end Prokemons Cada)or that he Is exempt ant I ram end the j eels for the alleged ASPHALTSHIN ES
a chit pen.Anyviolationoladan of Section 7031.5 by any s($500).):
$50 ).for a permit subjects the epplkenl to
e chdl,as of not mord then five hundred dollen with
"ga WOODSHA S �� ���J
❑I,k,and
Me Structure
I not I tended ogees with wapee as(Sec.their sole compensation,and will dorotes- / ❑
the work,entl Me structure Ls not Intended or offered for appy
(Sec.owner
of Bueineas who
Profes-
sions
O
Imps Ca de:The Contrecoc License Law does not applytoanowner ofproperty who build set WOOD SHINGLES `G
Improves merman,end who tlaeS each work hlmseit or through his own employees,provided Met \^� Q
such Improvements are not Intended or offered for cele.It.howwer,the bWMing or Improvement \ cv�
Is sum witNn onowner-builder e year of completion,Me will have Me burden of proving Met he did OT ER ISP �\ ,
not bulk]or Improve for purpose of sale.). \[ /
❑1,as owner of the property,em exclusively conimcllrq with licensed!contractors to cooswci \
the project(Sec.7046;Business entl Professions Code:The Commotws License Lew does not PROVIDE I.C.B.O�REPO/ 0.
apply to an owner of property who builds a Improvers thereon,end who conmacle for Such projects \��
with a contractor(s)
rs)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 aexempt under Sec. ,B 8 P.C.for this reon
as
owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under peneity of perjury one of the idlowing declaration: -
❑I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, BuflA
as provided for by Section 3700 of the Labor Code,for the performance of the work for which MU y b
permit is Issued. L
❑I have end will maintain Workers Compensation Insurance,as required by Section 3700 of ��• Seismic
the Labor Code,for the performance d Me work for which MIs permit is issued.My Workers -
Compensation Insurance carrier and Policy number are. ✓�L` TOtaR- L[!j
Carrier Pm>n•No. —`"LJ ���• PERMIT AUTHORIZATION DATE
CERnFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NOQ
(This section need not be completed it Me permit is for ane hundred dollen($100)or less.) Z l`
I certify met In Me performance of the work for which MIS permit U Issued,I Shan not employ `7
any person In any manner so as to become subject to me Workers'Compensation Laws of call- All roofs shall be Inspected prior to any roofing material Being
fon'a' installed. If a roof Is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
sub oto MayoArl APPLICANT: If Shp mak) Ike Certificate of Exemption
you should become Applicant understands end will comply with all non point
jecl pe pr you must brthwlth comply
MM such provisions or Inde permh shalcbe deemed revoked. - source regulations.
I cortlfyMet I have read this epplioatbn and state that Me above information is correct.I agree
to comply with 0city and county omlmnces and state laws relating to building constructbq and All roof covet to be class's or better. .
hereby authorize representatives of MIS dry to enter upon Ow abcva manUonetl property for In-
spection purposes. 1�
(We)agree M save,Indemnity end keep harmless Me City of Cupertino agamat liabilities,
• - judgments,costs and expanses winch may In any way accme age]=meld City In consequence RE F A NT DATE
of Me granting of Mie permit. -
PRE-INSPECTION: PLYWOOD: IN-P RESS:
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