R-6238 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R 62H-]
.
INSPECTION DIVISION PERMIT EXPIRAT10N
REROOF PERMIT (408)777-.3228 PERMIT EXPIRES IF WORK IS NOT STARTED -
WITHIN IN DAYS OF PERMIT ISSUANCE OR
• 160 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS& 113 IKIL'— (//CM�,C�
- RESIDENTIAL COMMERCIAL OTHER
OWNER'S - ` HAZARDOUS FIRE AREA
//•�� � YES [-IIfyes—I understand that a Class A
� J
NAME -'. C �• TIOC _ roo assembly is required.
NO Initial I.C.B.O.A
ADDRESS �Q'�'�^-"-- - EXISTING ROOF COVERING
PHONE
'S"T 3-3 NUMBER OF EXISTING COVERINGS
CONTRACJOF)'S
l/i/O• TO BE REMOVED � TO BE RETAINED
NAME '
ADDRESS s v 54..,.. TYPE OF ROOF COVERING
CITY a ZIP 40� tea- `�'II(v EXISTING
PHONE�61 50-'- 49.3 3 7 3 BUILT-UP ROOF -
LICENSE
NUMBER q x700 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION ^
I hereby afVmr that I sm Ilcensetl under provisions of Chapter 9(conaraend g with Section D SHAKES D [/�/'fC
]000)of Christen 3 of the Buelnesn and Professions Code,and my license b In lull lune and
effect. Ir 1j
(- c WOO NGLES
Uses"Clam `--� Uc.Number Y -A7o 0 /' / fJIAR 91999
dTh�R�9PE ❑
Data Contractor L
y
OWNER-BUILDER BUILDER DECLARA PROPOSED
hereby affirm Bu that am exempt hon the e: Any chy Llkense&county
Lew which
the following reason. By
- (Sec.]0315, ,Improas and ollah, tons Crile: Any cry a county which ,also
requires a permit to l
constnct,or Improve,olkto file signed air statny ement that
Is licenseor to Issuance,to
uires visione BUILT-UP ROOF C;d
of the nl for cuffs permit to Lae a signed statement that he Is licensed pursuant to the provisions
the '
of the Contractors lse ser Lew(Chapter 0 is ex a pt t with Section]000)of Division Me 3 le the '
'
Business entl Pro udonof Seco)or that he Ie exempt therefrom and the beefs for the alleged ASPHALT SHINGLES ❑
axemptlon.Anyf not ranof Section]031.6d any applicant for a permit eubteca the applicant to
e civil penally d not more Can five hundred dollars(f5W).):
C]1,as owner of the property,or my employees with wages as their We compensation.will do WOOD SHAKES ❑
the work,and
the structure is Trot Intendetl or offered for We(Sec.7044u
,BMu neand!Profits.
Siam Code:The Contractors License Lew does not apply to en comer of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work hknse6 or through his own employees,praMax!that
such Improvements are not intowetl or offered for Bele.If,honever,the silken or Improvement
It solo armin one year of completion,the owner-Ouiber will have the When of proving that he tlb OTHER(SPECIFY) - ❑
per WIb or Improve fer Purpose of sate.).
Ql.as owner of the property,am mcuslvety,contactln with ticensed connectors to construct
the protect)Sec.7044,Business and Proleealons Code:The Camrxtors Llcenee Law does her PROVIDE I.C.B.O.REPORT NO.
appy,to an owner of property who bullets or Improves thereon,and who contracts for such protects
with a contrsdorls)licensed pursuant to lire Contractors license Lew. PROVIDE MFGR.INSTALLATION SPECS.
Q 1 am exempt under Sec. ,B&P.C.for this reason
Owner' Data APPLICATION DATE VALUATION PERMITTEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under parlay of penury one of the Iolbwing cleclaradon: _e
Q 1 have aral will maintain a CeNflcate of Consent to seVansure for Workers Compomation,Section 3]000) / y+ gUllding
as provbeet for by Section 3700 of the Lobar Code,for the performerxre of Cro work for which this �C/�Q / ��� •
Permit is Issuetl. /`
horns and will maintain Workers Corm ticn Insurance,as required!by
Seismic
th�LeaWr Code.for the portermerlce of IN wwk for which this permit le Issued.My Workers
Corneensetion I [or Met Polity,number are: Total
Cerner ��—�i PdigNo.S_2/-99' PfBNfTAUTHORIZAT N DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE , N.C.0
(This Mellon need Trot be completed H the Permit Is for one hunred dodare(2100)or lose.) 3/
I cerGty that in the performance of the work for which thls perm,t Is Issued, shell not employ
any person In any manner so as to become subted to Ca W ars'Cumparaetion Laws of Cello Alls r shall be Inspects prior to any roofing material being
femla' 3/
- / q inst Iled. If a roof is'installed without first obtaining an
Date J_ AppllcerC inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It after asking this Certificate 6f Exemption,you should become- gppllcant understands and will comply with all non point
subtect to the Workem'Compensatlon proWeions of the Labor Code,you must forthwith comply
,with such provisions or this permit stall be deemed revakatl. source regulations.
yth� cou t� nnc s aelthe euidee�ctin�to replwihalndardiaand
netateiawsriangow Wilding All roof coverin s to be class"C"or better.
hereby authorize represenratives d this city to enter upon the ebovementlunetl property for in. ^�
specter,Purposes. a
(We)agree s save,Indemnify ty entl keep harmless the City ai st metra egehat IIBbIINIea,
tuppmens,costa and expenses which rtay In arty way accrue against Wtl Cly In coneapuenca
ol.rfre grenurgdthls Pumnn. - SIGNATUREOFAPPLICANT ATE
• , 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
OFFICE COPY