R-6576•
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PERMITR- 6576
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT cPIRAn 1
REROOF PERMIT (Q8) M-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
160 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/31i
RESIDENTIAL COMMERCIAL OTHER -
OWNER'S
KAZARDOUS FIRE All
YES ❑ It yes — I taldersfand chef a Class A
NAME �" ��-
roof essertlbly is required.
-
NO ElfrMe I.C.B.O. A
�� -
EXISTING ROOF COVERING
ADDRESS
NUMBER OF EXISTING COVERINGS Z�
? Z ' a
7r7 `
PHONE t -c.7 -
Z. 3
-
- -
TO BE REMOVED Z' TO BE RETAINED
CONTRACT0�
NAME—
ADDRESS
ADDRESS �SO c n - r?_ fJ n „'/J+A ay/'e
TYPE OF ROOF COVERING _
CITY a !T
EXISTING
PHONE (0So /93-637-3
RO¢F �c�\ ❑ - _
JV—v
BUILT-UPLICENSE
ASPHALTS f LES
UL 1 6 f
NUMBER qF2 7o O
UCENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provalons W Chapter 8 (wmmencing with Section
OOD SHA S
7000) of Dlvlslon 3 of the Business a" Professons Code, end my license is In lull lora and
effect G 3 O 0WOOD
SHI G� ES El
Ucense Close Lk:. Number
..
THER (SPECIFY)
Date Gant ec or
OWNER -111J. DER DECLAHATIO
I hereby affirm that I ern attempt from the Corrredors Ucenee Lew for the following reason.
(Sec. 7031.5, Suelmes and Proftnimus Code: Any dry or county which requires a parmlt to
construct, alter, Ill demweh, or repair any structure, prior to He issuance, also requbes the
BUILTU F ❑
appllCMt for mrw permit to flle a signed elatenwnt that he Is licensed Nmuant to the provisions
of the Contractor's License Lew (Chapter B (commenclnp wish Section 7000) of Divisor 3 of the
4go
Business and Proanalons Code) or that he U exempt tllerelrom and the basis for the stleged
exemption. Any violation of Section 7031.6 by any applicant for a permit subjects the applcent to
ASPHALT SHINGLES
L
e civil penally of not mora men five hundred tldtsrs
the do
WOOD SHAKES ❑ -
01, as owner of property, or my employees with wages as thalr sol° cumpsnsatlon, w46
the wore, and the structure Is not Intended or offered for sets (Sec. 7044, Buelneee and Paths-
slons Cade: The Contractor's Lienee Lew tions rot apply to an owner of property who build, or
WOOD SHINGLES ElImprove°
Ihenon, and who does such work himself or through his own employees, provided that
such Improvements are not Intended or offered for sale. If, however, the building or Improvement
badd within me year of completion, the owner -bulkier wIH hie the burden of proving duet he dill
OTHER (SPECIFY) ❑
not build or Improve for purpose of Bele.).
❑ I, as owner of the property, em exclusNNy conbenlnp wlm licensed contractors to construct
the project (Sao 7044, Business and Professions Code: llb Conma lou Uoeme Law wee not
PROVIDE I.C.B.O. REPORT NO.
ap y to an owner of property colo bullde or Improves maroon, end who continuous for such projects
will a centractor(e) licensed pursuant to the Connector, "me Lew.
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 am exempt under Sec. ,B a P. C. for this reason
Ower Dots
WORKER'S COMPENSATION DECLARATIIX4
APPLICATION DATE
VALUATION
PERMIT FEE
- I ;�
I hereby efflrm under Panel of perjury one of the following declaration:
❑ 1 have and will maintain a Cedlfleats of Consent to sal for Worker's Compensation, as
as provided for by Section 3700 of the Labor Code, for the performance of the work for wnIch this
� �
/ C(
g
permkleIssued.
and will maintain Workers Compensation Insurance, as required by Section 3700 o1
/'}
Seismic A-
3have
rut Labor Code, for IM performance of l work bin which this permul b issued. My Workers
C 11-nsu` far Polley
( e
Total
nVensetlon snit number aro:
S 7� 2�5
PERMIT AUTHORIZATION
DATE
Camor ✓� --�� Policy No.
- CERTIFICATE OF EXEMPTION FROM WORKERS' -
'
OOMPENSATIONINSURANCE N.C{]
(This section mad not be completed 4 tie parrrdt h for one hundred dollars ($100) or lees.)
I cenity that In the performance of the work for which mi, permh is issued, 1 shell net employ
arty person In any manner eo as to become subject to the Workers' Compensation Laws of Calk
All roofs shall be inspected prior to any roofing material being,
fefna.
7
installed. If a roof is installed without first obtaining an
Date (� Applcem
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, ,/ter making mIs Cer ifices of Exemption, you should become
subject to me Workero' Compemedon provisions of me Labor Code, you moat forthwith comply
Applicant understands and will comply with all non point
PP pts P
with such provisions or this permit shoe be deemed revoked.
Source regulations.
I curtlty that I have read mite application and state that the above Information Is correct. I agree
to comply wlm all dry and county ordinances and stele lam relating to buliding wnstructbn, and
All roof Coverings IQ be Class " or letter.
hereby authorize representatives of rule city to enter upon the abw rnemomd property for in.
ep cron(We) to
(We) at ,eve, Iodemnlry, keep mrmMu me Clry Ilebllnes,
�, (,z
7�i� /��
agree
entl egelnet
of st said
e, co
of the gnat, woof and exmniff. which may In any way accrue against aeltl City... consequence
of me grenNng of rub permd.
//
SIGNATURE APPLICANT 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY