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FFICE COPY
PERMIT
6569
APPLICATION FOR CITY OF CUPERTINO NUMBERR_
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
• WITHIN 160 DAYS OF PERMIT ISSUANCE OR
' 160 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
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RESIDENTIAL COMMERCIAL OTHER
W : l L/ l
HAZARDOUS FIRE AR EA
YES o II yes - I uxkrstentl they a Class A
NAME J • "�!� / Ly / /Y,v
roof essertldy Is required.
NO [d� '.InNal LC.B.O.N
TrTy W PA a4L
Lk-SS
EXISTING ROOF COVERING
-
ATdDRE
'
I
NUMBER OF EXISTING COVERINGS io/
'PHONE 10 a J'I
'CONTRACTOR'S - - �
nG per,/
TO BE REMOVED 70 BE RETAINED CJ
NAME
ADDRESS
CITY aZIP
TYPE OF ROOF COVERING .
EXISTING'.
\\
PHONE
BUILT-UP R- \U1 ❑
,� q9
19'
NUMBER
ASPHALT SHIN(illE6 2, El -CcNC
�tn� qty
LIC
LIaffirm Mat I am CENSEDCONTRACTORSDECLARATK)N
under of th Section
gentle (Ikrenssee
Division 3 of the 9usnneaatl
and Proteeedna Coderovisions
my IsInI forcer nnd
neon ,
rf
License Claes Llo. Number
WHO S
`'�\�T• f GV.TC-T` "
OTHER (SPECIFY) ❑
Data Contractor
K)N
DECLARATION
OWNER-BUILDERthe
PROPOSED
hereby affirm That I em exempt from the Lice Law for the foliong
Anymc(s
-
e: or roue reit t.
Bu se are Professions Cada: Any cily or county which requires a permit to
7ct,
constSec.
re air Acre, priortoIts l requires Ufa
alt r, mar ce, also,
construct,eller,Improve,
BUILT-UP ROOF - ❑ �/
for such parent to Ill. a statement Ilial he Is licensed pursuant to the provisions
todemolish,IIIsigned
of Me Co
of the Contractor's salons Lew (Chapter a o
r 9(comm 7000) of 3 0l the
(Chapter elan
Business Is anendrg
entl entl the heals for the canted
Codec or prof he la exampl omSectionand for the
ASPHALT SHINGLES
voleaelms
n of Section 70315 by any ant for i
ex ptiant for a permit subjects the applicant to
exemption. Mryf
not more Then five
e dull penalty of nem dollars ($5
1,
WOOD SHAKES - ❑
a pr y emptl yees;with "ge wdla-
as owner oftheproperty,or my employees; or eseren�! wepee to thensole compersa and
Ne work, and the entracte Is not ores for rale (Sec. 7014, ere Praleo-
doneCode : The not property
anwnordes:such Lewtlimelf apply toenowner elproperty whobuckleor
muse Law
WOOD SHINGLES ❑
Improves teener, and who doessuchwork or through his awn tethat
,
18th fmprmameme are not or Improvement
ed or or Improvement
a offered for sale. II, however, the
enobuilding
pleto , aha owner-0ulderMll have the When oiprovinpthat eaditl
netdtlld or
OTHER (SPECIFY) ❑
not Wlltl o Improve for purpose of tele.).
Imotyeeropurpose of
❑ I, sa owner of rhe Property, am exclusively contracting Mtn licensed contractor, to construct
the pralect(Sec. 70 , Business ano Professions Code: The Cornradoes License Law close not
PROVIDE I.C.B.O. REPORT NO.
apply to an omen of property who bulics or improves thereon, entl who contracts for such projects
with a contraca I licensed pursuant to rhe Contractor's License Lew.
PROVIDE MFGR.'IN$TALLATION SPECS.
❑ I am axe under Sec. ,B 8 P, C. for this reason
° rte Date
APPLICATION DATE
VALUATION
PERMIT FEE
r
WORKER'S COMPENSATION DECLARATION
Building g? .
I hereby affirm under penalty of perjury one of the following declaration:
1 have and will maintain a Certificate of Consent to Leaf -Insure for Worker's Compensation,
as provkled for by Section 3700 of the labor Code, for the performance of the work for which this
paten Is Issued.
J —21 �'
�
Seismic sO
1 have end will maintain Worker's Comnprance, en
ensadon Insuas required by Sect3700 of
the Labor Code, far fee Performance of the wark'for which this permit is Issued. My Worker's
(
(�
-Compensation Insurance carter and Policy number are:
Total
Cerner Posy No.
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 '
(Tela aecffon need notbe completsd It the permit le for we hovered dollars ($100) or less.)
'
I cordly whet In Ne pedomunca of Ne work for whdJn Nle Permit le lesum, I ahall not amp"
any person In any manner so at to become subject to the Workers' Compensation Levee of Calk
Allrootsshall be in ted prior to any roofing material being
Iomla'
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become
subject to the Workers' Compammdlon provisions of the Labor Code, you must forthwith comply
Applicant understands and will comply with all non point
with each provision or this permit shelf be deemed revoked. -
Source regulations.
I certify that I have read this application and state that the above Information Is correct.I agree
to comply with all dry and county ordinances and state laws relating to bolding construction, and
All roof 5jvenngs to be class 'C" or better.
hereby authorize representatives of this city to enter upon the ebove,m<ntloned property for in-
spectlon purposes.
(We) agree to save, Indemnify and keep harmless the City of Cupertino opelnet danlldes,
- u ments, coats and expenses which may In any way accrue against said CityIn cansequerwe
of tBe prendnp of Ihle paten.
SIGNATURE OF APPLICANT DATE
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
FFICE COPY