R-6285 APPLICATION FOR CITY OF CUPERTINO
PERMIT BER R- 6285
INSPECTION DIVISION -PERMIT EXPIRATION
REROOF PERMIT (408)777-.3228PERMIT-EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
x 100 DAYS FROM UST CALLED INSPECTION.
• BUILDING ADDRESS
/AAA �QJ�/J, c ep226, C.
/"C6�"'' S( L.0/CK OR � RESIDENTIAL° COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
�( ��,r• YES ❑ If yes-I understand that a Class A
NAME— P ` 1 ` is rod assembly is required.
:l (��Q' ��//
NO El - ROOF
I.c.B.o.a
ADDRESS }` .EXISTING ROOF COV/EKING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACT 'S - -
` - TO BE REMOVED TO BE RETAINED
NAME If
ADDRESS % �77'/DY'y �.7( U TYPE OF ROOF COVERING
CITY aZIP—
EXISTING
PHONE / e a'p3 ?'2 -7 7 BUILT-UP ROOF ' ❑
LICENSE
NUMBER /7 O ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensee under provisions of Chapter 9(commencing with Secuan WOOD SHAKES —
]000)of Division 3 0r'the Business and Professions Code,end my Iberree Is In full bice and
aceta + D WOOD SHINGLES El Class e � / Llc.Number ��
OTHER(SPECIFY)
Date �73Damneder _ - �/
SOW EER-BUILDER DEC PROPOSED eO
hereby . irmBu that am exempt from the e; Any city or coup Lax for the blbwag reason. v
(Sec.]031.5,Bu
siness and demolish,
or repair
Caen: Arty dry or county which requires a uir s t to _
construct,eller,lmpro+it d file a s, nedstatement
t eny menstructure,is Poemor to Is iesuen nt after to U,requires BUILT-UP ROOF ���
of me mfor cure Permit to Ills a signeddr 9(commthathe 1ISec Section
pursuant toere prwof the
of the s and
Uceroe Lew(Chapter 9 Is ex a exempt
welt orn ar l]000)of Division me 3 of the �Business usentl viola on of Code)or that he Is exempt antfarom arm the Beale ler tea alleged! ASPHALT SHINGLES
exemptlon.Any vloletlon of Section 7031.6 by any applicant ler a Permit euaede the applicant to
a all penalty of act more Man Me hundred dollars(5500).):
C]1,as owner of the property,or my employees with wages as their sole comreneatim,will do WOOD SHAKES ❑
the work,and the structure le not Intendant or offered for sob(Sec.]Oslo,Buslnese and Prafes-
sions Cade:The Contractor's Licenaa Law does not apply to an owner of property who Wilds or WOOD SHINGLFyS��
Improves Marson,and who does such work himself or through his own employees,provided mel
such Improvements are not Intendant or offered ler and.If,howwer,Me bolding or Improvement //q
is sod within one year of camoetbn,the owner-builder will have the Whson al prwing that he tld OTHE ' ECIFYY�
net O 1. or Improve ler Purpose of sale.).
xclu (�"
❑L ee owner of the property.and Profevery cs Cod tlrq with Ilceneed camewdare to acaui net
the project(Sec.]04t,Business and Proleeelans Cade:The Corrtrabtor'e ucerree Lew aoee not PROVIDDDEEE�I.0 B OvRFiP(3R�98.
appy to an owner of property wbo builds«
sImproves thereon,and m
who comrade ler such projects `I F� r�`O
with a mntrectogs)Ilconsed pursuant to Me Contractors License Law. PROVI E MF R.INSTALLATION $P CS.
❑1 am exempt under Sec. ,B&P.C.ler thisreason
Omer Data APPLICATIOIS ATE PERMIT FEE
WOR10=R'S COMPENSATION DECORATION PATE A
I hereby affirm under penalty of perjury one of the following deciaretlon:
❑1 have and will maintain a Certificate o1 Consnrll to self-Insure for Worker's Companeatbn, Building L// 7
as provided for by Section 3]00 of the Labor Code,for ft performance of the work for wNlch this permit leaw
issued. $eSmIC
I hwre entl will melnMln Workers Compeneatlon Ineurenm,ee raqulretl by 9edkm 3]OO of
-me I-olborpQd1c,ler Ma performance of the work for whin this pernnt is Issued.My Worker's
Compan
JcN Insurance terrier and lay number ere: _ / Total
Cerner Policy No. NW C, Sys PERMIT AUTHORIZATION DATE -
CERTIFICATE OF EXEMPTION FROM WORKERS 03
COMPENSATION INSURANCE
N.CJ_]
(The secllon need not be mmpleted If the permit Is icr one hundred dollars($100)or loss.)
I tartly that In the performance of Me work for which this permit is Issued,I shall not kers' emvMry
any person in any manner so as to became subject to the WorCo nWasaLaws ten of Call. All roofs shall be inspected prior to any roofing material being
.feria. installed. If a roof is installed without first obtaining an
Date Appucent inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,atter making this CerdOcale of Exemption,you should become Applicant understands and will tom with all non int
subled to Me Workers'Compervsatdn provisbne of the Leber Conte,you must forthwith compy PP comply PD
with such provisions or this pennt shalfjbe deemed revoked. source regulations.
I certlty that l have read thle application and state that Me above Information to correct l agree �I�(jJ�j'�/
m campy waft all dry erdmunry of this cee end ter upon
theleungtoeentiogmrmperty in- All f g l r cla�ba er./
hereby authorize repreeantethoe of this cny.lo enter upon the above-ntentloned property ler In- C.
ep purposes.
(We)
(We)agree t, save, pnscaIndemnify and keep themes"nywathe City of t card Cl epelnst IIeGIWes, r �/
utlgmentn costa and permit. a which may In any way ettrue agonal Bald Clry In consequence
i) al Me grentlnp of this permlf. SIGNATURE OF APPLICANT DATE
RE-INSPECTION: PLYWOOD: IN
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