R-6325 TY OF CUPERTAPPLICATION FOR ClINO
NUMBER PERMIT R- 6325
■�
INSPECTION DIVISION PERMIT E(PIRATI N
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
- 180 DAYS FROM UST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
owNE ' HAZARDOUS FIRE AREA
it C,\ YES ❑ r yes—I mblyunderstand tired a Class A
NAME root assembly Is required.
NO . ❑ Initial LC.B.O.N
PHONEzw
— 3 7 NUMBER OF EXISTING COVERINGS
' CONITRACTO 'S a{�
TO BE REMOVED "" TO BE RETAINED
NAME _
ADDRESSi TYPE OF ROOF COVERING
CITY a ZIP, C EXISTING .
PHONE (IJS D.'��o ( l ar•} BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION -
I hereby affirm that I em Ikensad'under provisions of Chapter 9(commencing with Section WOOD SHAKES /
7000)of DMelon 3 of me Business and Professions Code,end my license is In full force end
affect. I WOOD SHINGLES
License Class uc.Numbs r' /
Date — Contractor OTHER(SPECIFY)
I 9�
OWNER-BUILDER DECLA TION PROPOSED
hereby ,Bu that am exempt from the Contractor's or roue Lew for the fallowing motion.to
(Sec.7031 S,Buame*s and Proh,or rep Code: Any ay or county which requires a permit to -
conrruct.alter.Improve,dfilea pnor to its lvuerKnt taim o the
BUILT-UP ROOF ❑
applicant for such permit to La (Chat statement met he le licensed pureuenf to ma pro of the
of Ne Comrectore...I.. Law(Chapter 9 is
emptp with Section]000)a Division 3 0l the
Business end Proflaflon of Coda)or that he la exempt thenar the applicant
to
ASPHALT SHINGLES
exemption.Any ltyof of ore Section hurldbbyerry applicant lore per auq t applicant to
e cMl penalty of not more man five nur'dreq dollars(ssool.l:
❑I,ae owner of me property,or rrcy empl sae wlm`wegae ee me Iec non,will do WOOD SHAKES ❑
the work,and the structure is not Intantled'or offered for Bele(Sec.7044,Bu n and Profee-
Blom Code: The Contractors License Illfaq does not appy to an owner of ro ho builds or WOOD SHINGLES
Improves thereon,era who does such workpid drlmro gh�yb O�]r� oy� rwlded mel ❑
such Improxoments ere not intended or unwed lar tale/If, wbver�H{� til mprovement
Is*ofowithln oneyeerelmmpefbn,theownerWifoarwlll have the burden ol�lpthat he dol OTHER(SPECIFY) ❑
not bul d w Improve for purpose of sele4U '
❑1,as owner of me property,turn exclusively conlrechnp with ticensad corrector tommstruct
me project lsec.7044,Business and Prbfmlpns Cade:Tne Contractor*uce wdoee.1 PROVIDE I.C.B.O.REPORT NO.
awryto an owr l Property who bulldsorimprmee lner uch projects
with econireaor(s)laensed pursuant tdthe Cdnir'actoreL neo Law. PROVIDE MFGR.INSTALLATION SPECS.
F7 am exempt under Sec. ,B A P.C.for this reason
owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION!
I hereby affirm under penalty of perjury one of the folbMng dedereticn:
❑I have and wit maintain a Certificate of Consent to saif-insure for Workers Compensation, � Building
as provided for by Seaton 3700 of me Leber Coda,for me performance at tine work for which MIB
permit is Issued.
ction / �( V 581Sn11C
❑ ve I haentl Mil maintain Workers Compeneaton Insurance,es required by Se3700 r
the Lebow Code,for me performance of the work for which this permit Is Issued,My Worers Total 5`_7_3_
O
Compensation Insurance caller and Polity number are: �� / O' n V M�`
Cerner Policy No. OY L PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(This section need nor be completed If the Permit is for one humored dollar*($100)or lase.) /z 7 /
1 certlty that In the Performance of the work for wnfoh mle rmn Is Issued.I shell not employ
any person In any menner Be as to become sub o the W r re'Compensation Laws of Call- All roofs shall be inspected prior to any roofing material being
fouls. installed. If a roof is installed without first obtaining an
Date Aapfo*nt v inspection,I agree to remove all new materials for inspection.
NOTICE TO APPDCANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non Int
subject to the Workers'Compensation provision*of the Labor Code,you must forthwith comply pP P Y Po
with such provisions or this penult Bhalcbe deemed revokedsource regulations.
I certNy mal I have react mlB application and state that the above Information Is conacL I agree
to comply with all city and county ordlrrenceB end state laws relating to building mnetrucdon,entl ven sto be class"C"or better.
hereby authorize ropresenmfNee of this dry to enter won th e0ave-mentioned properly for I
specion pumoees. O\/
(We)agree to ee",Inclemently end keep keep hamness the Cly,of Cupertino against IIawl as, 19 _7
julments,cora and expenses which may fo arty way accrue ..said City N tames_
all 0 granting of this permit. SI ATUR F APP L NT DATE
k?RE-INSPECTION: - 'PLYWOOD: IN-PR SS:
I
t 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