R-6284 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R" 6 Z H 4
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORT(IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING IDe,S <
Z-- OS
n
- / L.I�'e r DKsaa.o� d!.(In �t RESIDENTIAL - COMMERCIAL OTHER
OWNER'S . HAZARDOUS FIRE AREA
s i L (/ e 1� ¢ KS �✓ f 7' c� vas ❑ u yte s l unae is req utas. Chase A
NAME cool assembly is required.
' �y/_ /y7//�� ` NO ❑ Initial LC.B.O.O
ADDRESS_•�' /U P L a
EXISTING ROOF COVERING
PHONE' (' T— —1 Ly,y NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
• NAME— TO BE REMOVED _ TO BE RETAINED
ADDRESS
_ TYPE OF ROOF COVERING
p ( ./ / �
CITY&Zip— / SCJ"/ IO /, c�Q /V <3 S P 3ISTING .
PHONE 7 /C 7 7 BUILT-UP ROOF- ❑
LICENSE ❑
NUMBER . I c9O CONASPHALT SHINGLES
CONTRACTORS DECLARATION '
I hereby affirm that I em Ikensed urger provisions of Chapter BSwmmancing with Sactbn WOOD SHAKES .
7000)of Division ass
n 3 of Business end Profone Cade,and my kande Is In full kirce and
q L
C•3 `� 7
Date �p / O WOOD SHINGLES' ❑
enw. Close Lk.Number I p
Date l 1? 3 / caniredor C 4 R6 O ye��d'� OTHER(SPECIFY) !❑'
OWNER-BUILDERfromMDECLAFATIOfJ - PROPOSED
hereby. ,Bu that am exempt from the e: Any cry or c u n Lew for the uir s a rnew. /
(Sec.7031.5,Business and dish,Profiess0onsrel Code: Any dry or county which requires requires permit b
applicant,alter,Improve,domto fhe as n repalrem ntrthat e, s tic to Its lesuance,to ethe BUILT-UP ROOF
applicant tr such permit a Iib a elgned statement that he le t licensed pureuaat to the provisionsatthe '
at the ss and
Professions
Lew()heeler B is exempt
therefrom
om amn 7000)of for the 3 0t.the
.
exemption.
end P iclatl one Code)or Net he le exempt therefrom erm Hte belle he the ical to ASPHALT SHINGLES
axemptlon.Any f net more Man
Section 7031.5 hundred my applicant fora permit eublecte the appllcent to
e civil perelry of not more then Hve hundred dollen(5500).):
❑l,as owner of the property,or my employees with wages as their sole compeneatlan,will do WOOD SHAKES ❑
the work,and the structure Is act Intended or offered for sale(Sec.7044,Business and Proles-
alone Cade:The Contractor's Llcense Law does not sop to an own rty who builds or WOOD SHINGLES
• Improves thereon,eve who does a werkhlaRe HR g em as,,prodded that ❑
such Improvements are not Intend! Herod II,h a the or Improvement
lased withln one year of wmpletlo nor-sl u`W(i have Wrde oving that he am OTHER(SPECIFY) ❑
not build or Improve for purpose of
❑I,as owner of the property,am eNelywntrectinp wlthicensed t ore to construct
the project(See.7o44,Business 5 aLav does not PROVIDE I.C.B.O. REPORT NO.
appy to an owner of property who art N a n kr such enacts
with a contractor(e)k cased pursu o the Central e Lkeme Lew.
❑1 am exempt under Sac. ,B .for this reason PROVIDE MI INSTALLATION SPECS.
ownerWORKSS Det APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury crap of the following daclaradon: ^r�� es, r
❑1 he"and will Mal Man a CenlHcate of Consent to aetldnaura for Workers Compensation, J 2 BDlld Ing `
as,provided for 1y Section 3700 of the Labor Code,for the performance of the work for which this
Permit le leeued. - / C� n
❑1 have and will maintain Workers Compensation Insurance,as required by season 3700 of / ( %• `'1 Q t D do Seismic e470
the Labor Code,far.the performance k k
of the wanr which this pernit is Must.My Workers ((
CanpensaHon Insurance terrier and Policy number are: J TOtal�
Uoro
coder CQ = - Policy No. l/G� PERMIT AUTHORIZATION DATE
CE;TFl E OF EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE N.C43
(This section need not be completed H Ne permk le ler one hundred ddlere($100)or leas.)
wrTty that In the performance of the vrork which this,permit Is Issued,I shell not employ
any person In any manner w es,to become e l to the Workers'Compensatlon Lewy o )alb All roofs shall be inspected prior to any roofing material being
lemic' installed. If a roof is installed without first obtaining an
Data 1� `✓'4 Applicant Inspection,I agree to remove all new materials for inspection.
subeact to are ere'Com ansatbn provisioVr: 11,aftor Making ns of Me Labor10E�you you should became Applicant understands and will comply with all non point
Ps pr you must brNwlN comply
wiN eudr provisions or Nle permit e.aH be tleemetl ravu6etl. SOUfCe regulations.
I cartily Net I have read this application end state Net the above Inkrmatkn Is coned.I agree
to comply with all city and county onfirmnces and stale laws relall to Wllding conslrudbn,and AI of Coverings to be class-6
oorr better.
J'
hereby herauthorize rspraeantadvaNrn
s of this dry to enter upon e above- enHoned property ler In-
hereby purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino apalnst Ilebllitles,
judgments,wets and wipers"which may In any way accrue against sold C.,In wnsaquence SIGNATURE OF APPLICANT DATE
of the granting of this permit. '
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