R-6287 PERMIT
APPLICATION FOR CITY OF'CUPERTINO �.NUMBERR- 6.2 8 7
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT .(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1130 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS —_ (I� /�(�����U
a 47 G S i d e ►- V�(j L� RESIDENTIALt�v COMMERCIAL OTHER
—
OWNER'S
/ (/Y� c p HAZARDOUS FIRE AREA
NAME W Q ��� v e®r 7 (� - VES ❑ �a�m bly is req iret, Class A
bhY Is rrsgtrired.
' NO ❑ Irrigel I.C.B.O.A
ADDRESS a'-�-�e7 �' �e r `-""'t2 EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
` - TO BE REMOVED TO BE RETAINED
NAME
n�DREss c
T�Y TYPE OF ROOF COVERING
crlvazlP .
EXISTING
PHONE i'Zd /e l ip1 -2 �� 7 BUILT-UP ROOF ❑
NUMBER .6 7 / 0 - ASPHALT SHINGLES ❑
-LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 0(commencing with Section 'WOOD SHAKES { -
]000)of DM'alon 3 of the Business and Professors Code,antl my license Is In full force and
effect ��/4 �/,.s =4112/�—p� WOOD SHINGLES
Uce�cfes? Uc.Number D O ❑
Date
CL OJ [%A, OTHER(SPECIFY)
/ J
OWNER-BUILDER DECLARATION - / PROPOSED /
hereby affirm that am exempt from the Contractors orUcansemun Lew for the requires
a roe /�_o
(Sec.construct,
b, Business and Proleeor rep ur an Any dry or county i requires a uirmfl a f0(/
conetrud,after,
sucftImprove,
ermittl filen signed statement
structure,p licensor to ed l Pursuant tborequiresthe BUILT-UP ROOF [�
of the
ler sudr permit to Ills a signed r 9(comm that he b licensed Pursuant D the prwisbna
of the Professions
Contractor's License Lew(Chapter g(commence with Section Me b of DMslonm 3 G the '
•
exemption.
and Pro lotion f Code)or that.he re exempt therefrom antl the beets for the elbgetl ASPHALT SHINGLES
exemption.Artyvacationof Sectionthe hunar q'any epplimnt lera permitsWjeOa the applicant to
e chid penalty of not more then Ifva hundred tldlare($SOOI.):
❑I,as owner of the property,or any employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,end the structure is not Intended or offered for sale(Sec.7044,Buelness and Profes-
sions Code:The Contractor's LicerueLew does not appy to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does each work n himself or through his owemptoyees, e prod that
such Improvement are not intended or offered for sob.If.however,the building or Improvement
.
is sok!within one year of completion,the owner-builder will have the burden of proving that he db OTHER(SPECIFY) ❑
not bulb or Improre fwe
for pure of Bab.).
❑I,as owner of the property,am exct meanly contraming MM licensed contractors,to canmrucY
M project(Sec.7044,Business and Professions Code:The Conaactore Ucerte law does not PROVIDE I.C.B.O.REPORT NO.
appy to a owner of property who builds or Improves lhaeon,arM who canVact for such projects
with a contractors)licensed pursuant to the Contractors License Law. - PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.far Mis reason
°" °r Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: Z
❑1 here and wis maintain a Cermloate of Consent to seff4rmure for Workers Compensation, - BU lding�
as,provided for by Section 3]00 of the Labor Code,for the perbrmawre of the work for which this q
permit Is Iesum. / /
❑1 have and will maintain Worker
°Compensation Insurance,as required by Section 3]00 of ( Q IC
the Labor Coda,for the part of the work far which this peunh Is Issued.My Workers /,1
'Compensatl neumnce carrier Pdicy number are: Ir T r O
Carrier ! Po1cyNo. /' Sys / PERMIT A }i0 I - TiION Q DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'. d
COMPENSATION INSURANCE N.CL]
(This section need not be completed If the permit Is for one hundred"late($100)or less.) C' 1 .r✓
I candy that In the performance of the work for which this permit to Issued,I shell not empty
any person In any manner so as to became au a Me Workers'compensi twn Laws of Call- All roofs shall be inspec(gc,1 plIgLL4,aDKrQo6Dg � aterial being
fornia. installed. If a rdof'is'Installed-WiThout-fir8t-obtaining an
Data_4 'LApplicant — "—`��•� inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,after making this Certificate of Exenptbn,you shout become Applicant understands and will I with all non int
subject to the Workers'Compenaatlon prormlons of the Leber Code,you must forthwith campy, App comply Y point
with such provisions or this permit shoSbe doomed revoked. source regulations.
I certily that I have read this application and state that the above Inform°tlon Is correct.i agree
to comply with all city and county ordinances and state laws reatg to bulking corvatructlm,end Aoof coverings to be lass better.
by
hereeuttwnze rapresenatives of Uls city to enter upon Na above-m
oentioned property for In-
hereby purposes.
(We)agree to sere,Indemnify and keep harmless Ne Clry of Cupenfno against Nadlltlee,
of Ne gmad g°o hLe PerrmiL Ich may In any way accrue epelnet said City In corrsequerrce SIGNATURE OF APPLICANT DATE
�'RE-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