R-6572 (2)0
0
OFFICE COPY
PERMIT R_ 6572
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 7-n-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM UST CALLED INSPECTION.
BUILDING ADDRESS
/ Z/(O 3
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
LtACL"%'N"`—
YES ❑ ff yes - I understand that a Class A
NAME
roof &%sea * is required.
NO ❑ - 111 LC.B.O. Y
C �Q
/�
ADDRESS 947 v�Q V'L`A' s cLA
EXISTING ROOF COVERING
/
2 Z
NUMBEROF EXISTING COVERINGS
PHON .2-60 /
.
TO BE REMOVED TO BE RETAINED
CONTRA OR'
NAME
ADDRESSJ✓✓ C/, �j ' D
�l - �`�u
TYPE OF ROOF COVERING
CITY & ZIP / (
EXISTING, -
473 3 7 3
PHONE Ill •
BUILT-UP ROOF ❑
LICENSE 0-27
NUMBER O Qct
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
WOOD SHAKES '
7000) of Dlvbbn 3 of the Business and Professions Corte, and my license Is In full force and
effect.
-s p p
`
WOOD SHINGLES ❑
Number
Date
` D r
mac--
OTHER (SPECIFY) ❑
Data (_pLLiip convenor
co
OWNER.BUILDER DEC ON
I hereby affirm that I am exempt from the Contractors uconee Lew for the Idbwing reason.
(Sec. 7031.5, Butane and Profar lone Code: Any city or county which rw lree a permit to
construct, alter. Umprove,demolish, or repalrany structure, prior to He Issuance, else requires the
ILT-UP ROOF ❑
applicant for such permit to is a 4gnW statement that a Is Ibamed pursuant to the provbbns
of the Conta or, Licen,e Law (Chapter 9 (commencin wch 9ectlon ]000) of Divbbn 3 of the
Business and Professions Code) or that he b exempt It arehom are the bees for the staged
ALT SHINGLES iR ry (7 y1
exemption. Any vldatbn of Section 7031.5 by any applicant for a permit sublease the applicant to
e chill penalty of not more than III hundred dollars (SSOOW:
W00 A S
❑I, as owner N the property, cr my employees with wages as their sola compensation, will do
Cl
Me wok, end the stmctune Is not Intended or offered for sole (Sec. 7044, Business and Profee-
Nona Code: The Contractors Lomas Law case not appy to an miner of property who builds or
WOODS ❑
Improves thereon, and who does such work himself or through his own employees, provided that
such Improvements we not Intended or offered br sale. If, however, the Wilding or Improvement
is add within am year of cempledon, the owner-bubdsr will eve the burden of proving tet he did
OTHER (SPECIFY) ❑
rat build or Improve for purpose of
Me0prolect (Sect 70", Suracul the `operty mon entl P Iea�elons,Code Ttralhwith
Con�vanclodre "me`Law�cl not
PROVIDE I.C.B.O. REPORT NO.
appy to an owner of property who bunds or Improve thereon, and who contracts for such "ems
with a confractims) Ikenee l pursuant to the Contractors License Law.
PROVIDE MFGR. INSTALLATION SPECS.
❑ I em exempt under Sec. B B P. C. for this reason
' owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
19
I hereby affirm under penalty, of parlury one of the follvMrq dscemtipn:
❑ 1 have and will m dirmin a Certiticete of Coneent to nti-nsure for Workers Compensation,
as provided lar by Section 37M of the Labor Code, W to performance of the work for which thio
perm9bissued.
` ^
�00
�^
9,JOO
Building
have ere will melnaln rmarWorker's C the woatbn Insurance, as required by Section 3700 of e
the Wr Code, for tine pmformenca of the work for which this permit Is Ieauad.My Workare
•J /-7 Qq
Seismic
pensetb ne�u "�` carrbrerePolicy number ere:
Total
�c
��'�'�-+ 7�Y/
PERMIT AUTHORIZATION
DATE
Carrier :-�'/41'� POIIryNo.�7
WORKERS'
CERTIFICATEEN COMPENSATION INSURANCE
COMPENSATION INSURANCE N.C{J
(This norm need cwt be completed N the permit Is for one hundred dollar, ($1 M) or leen.)
.I certify that In the performance of the work for which this permit Is Issued, I shall not employ
any, person In any manner so as to become subtert to the Workers Compensetlon taws of Can-
All roofs shall be inspected prior to any roofing material being
fomla.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
IN CE TO PLI ANT: If, after mu ing this Cerft a of Exemption, you should became
'subject to the Workers' Compensation provolone of the Labor Code, you must forthwith comply
Applicant understands and will comply with all non point
with ouch provblona or thio permit shall be doomed revoked.
Source regulations.
I certify that I he" mad! this application and sate that the above Information Is correct. I agree
to comply with all dry are county ordinances and sate laws relating to building consbuctbn, al
All roof coverjjlgs B class Or better.
thorize
hereby aurepresentatives of this dry to enter upon the above-mentionedop
prerty for In.
spechon purposes.
4,
"
(We) agree to ,eve, indemnify are keep ermlas the City of Cupertino against Ilabllldaa,
R//
Judgments, cava and expenses which may In any way accrue against sae City In consequence
SIGNATURE OF APPLICANT DATE
of the granting of this permit.
-
PRE -INSPECTION:
PLYWOOD:
IN -PROGRESS:
INSP. DATE
INSP. DATE
If 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