R-6417 PERMIT R_
APPLICATION FOR CITY of CUPERTINO NUMBER 6417 .
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT ' (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED-
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
y� BUILDING ADDRESS
(
RESIDENTIAL" COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
rn� �or� VES ❑ Ifrof amemdy is req Iced. ClassA
NAME `�1 C root assembly is required.
� NO Initial I.C.B.O.N
ADDRESS f EXISTING ROOF COVERING
p
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTO,R�J,S n f - Sures TO BE RETAINED 1y
NAME
/I UyQ I /rUU rj�d TO BE REMOVED
ADDRESS // ''II TYPE OF ROOF COVERING
CITY
&ZIP
&`7,S
7 EXISTING
PHONE J� -BUILT-UP ROOFLICENSE
❑
NUMBER ASPHALT SHINGLES
NUMBER 7y!/ ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under providorn of Chapter 9(commencing with Section WOOD SHAKES
7000)of DMsbn 3 of the Business and Professions Cade,and rtry license to In full force and
effect.
4 �/j WOOD SHINGLES E-1Llcenee Claes I I Number `� //�r
Date 18 �y Contraaor OTHER(SPECIFY) ❑ /
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm Vaal I am exempt from the Contractors License Law for the blowing remain. !!
(Sec.7031.5,Business and Profeeelmm Cotle: Any chy or county which requires a permit to /
construct,alter,Improve,demolish,or repair arry structure,prior to Its issuance,also requires the BUILT-UP ROOF El
for such Permit to No a signed statementsed bum
that he Is licenpursuant to Me proNs
of Me Contractor's Ucense,Lew(Chapter 9(comnhendnq with Section 7000)of Division 3 of the 7
Business and Professions Code)or that he Is eaampl therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any vldatlon of Section 7031.5 by any applicant for a permit subjects no applicant to
e clvll penalty of not more than five hundred dupers($501
❑I,as owner of the property,or my employees with wages as erelr sofa compensetlon,will do WOOD SHAKES ❑
the work,end Me structure Is not Intended or offered for sale(Sec.7044,Du nes a end Press-
ebnsCode:The Contractors I-ceruse Law tloas not apply to an owner of property who Wilds or 'WOOD SHINGLES
Imention,proves mention,and who does such work himself or through his awn employees, tha
ryees,provet ❑
such Improvements are rot Intended Or offered for sale.If,however,the building or Improvement
Is sold within one year of complenon,the owner-builder wig have Me burden of proWug that he dM OTHER(SPECIFY) ❑
rot build or Improve for Purpose of sale.).
❑I,as;manor of the property,em mclust ely contracting wtlh Ibaru¢tl contractors to construct
the pmjed(Sec.70",Business and Pmfessbro Code:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who Weds or Improves thereon,and who contract M such projects
with a contractors)licensed pursuant to the Contractors License law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner' Date
WORKERS COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the IolbMng declaration: /�
❑1 have and will maintain a Certificate of Consent to een-Ineure for Worker's Corripensatbn, Building
as not is l tl for lxy Section 3]W of the Labor Cade,ler this perbrmence d the work ler which MIs �•x` ^ p. y� r
perM1 hemi, ed. off/ l/y /`y v� Seismic
-11 have and will maintain Worfermnance, f the w efor Insurance,as required by Section 37W of i
.the Labor Code,ler the pedarmanc�a of the walk ra which this permit Is Iseuetl.My Workers
Compensation Ineuranca c1ensre�frand�Uty number are:'�./ / � Total
Canter`"(� /IiJ•"nQ f• �Wo(ky No ar sao�(�6If PERMIT AUTHORIZATION - DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ /1
(This section need not be completed if the permit Is for one hundred tldters(S100)or tees.) 7 /y
I ceinty whet In me pe formatnce of me war,for which this penult Is Issued,I shall not employ
any person In army manner so ae to become subject to the Workers'Compo�gp�n Laura of Calf- All roofs shall be inspected prior to any roofing material being
terms. _fp �//,�1 installed. If a roof is installed without first obtaining an
Date o Applicant ^�"�f inspection,I agree to remove all new materials for inspection.
e�On too the CE TO In�a�rkoivn6�softheLa�o1�oumusvehawabaaame Applicant understands and will comply with all non point
j p p you must forthwith comply
With each provisionsatIIan, r Mit the
ehation deeTndst ae invthat the. $OUTCe regulations.
comply
whet have and Mieeordin ncentlawmetel the above informal Wilding Iecorrect agree
to hereby author en city and county of this
and ser u ern relating to Wilding construction,property
end All coo s to be ass or better.
hereby authorize represenletWea of MIs dry to enter upon iha above-mentloned prapelty ler in-
spection agree too.
(We)apse s save,Indemnity arc keep h any
way cc City a Cupof connold Ci against Ieque ce J CC
of a grantinngg of and
Permit. which may In arty way accrue against Bald City In wnsequerore• 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 ACCESS TO-ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY