R-6390 PERMIT
APPLICATION FOR CITY of CUPERTINO NUMBER R' 6390
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
• WITHIN DAYS OF PERMIT ISSUANCE OR
180 DAYSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
t-"� RESIDENTIAL_`ACOMMERCIAL_OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ N yes-I understand that a Class A
NAME 1Kh �r �S. .�- f assembly is required.
NO Initial I.C.B.O.#
ADDRESS l O y1 Z (r/�.v V l �"�' EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERT Sy
CONTRACTOR'S y0
NAME 2 4A.1e-- Ger' -✓• TO BE REMOVED TO BE RETAINED
ADDRESS
n0 ,f� TYPE OF ROOF COVERING
y f0�
aTvazlP P- EXISTING
PHONE 7 7—cd 33 BUILT-UP ROOF ❑
CENSE
NUMBER 6 7 29 Z f5 ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby eHlrm that I am licensed under proAslorvs of Chapter 9(commanxbng with Section WOOD SHAKES ❑
7000)of DMalon 3 of the Business and Professions Code,and my license is In full force and
effect.
S WOOD SHINGLES El
uoenea class �-' 3 up.Na 9 i b -
Date/�?G� Q`f contra OTHER (SPECIFY) z2z
❑
OWNER BUILDER DECLARATION PROPOSED
hereby ,Bfl that I em exempt from the a Any or'schy or cone Lew for the lcffrequires
ng reason.
(Sec.]031.5,BImpro e e demolish,Professions it any Arty dry or county which ca.also a parmlt to
cpplican or suimprove,to
signed statement
Nure,priIsor to us ansed!pursuant to
he qulrse Ms BUILT-UP ROOF ❑
apme co for each parmlt to flaw a signed statement that hw Ish erred pere00af to the provisions
• of the ss and Prs Usines Lew(Chapter 9(commencing with Section Me
of for the 3 0l the
Business entl v"ataboa Smh or that he is exempt therefrom a and me basis for applicant
icant to ASPHALT SHINGLES ❑
a civil en.Any violation of Section 703dr by arty applicant for a parmlt subjects the applicant to
e civil penalty of not more Than flog hundred yeas (h wage: WOOD SHAKES
❑I, , ander of the property,or to employeesred wages as,theirsolo compensation,wle do ❑
Me work,entl the structure is not Intended or offered for sale(Sec.7041,Business entl Protea-
along Code:The Contractors Ucense Law does not appy to an owner of property who builds or WOOD SHINGLES ❑
Improyea thereon,and who does such work himself or through has own employees,provided that
such Improvements are not intended or offered for sale.If,lwwever,the building or Impra.ement F
is gold within one year of completion,the oavner-builder will have Me burden of pr cm Mathedld OTHER(SPECIFY) ^
not bulld or kinprove for purpose of ease.).
01,as owner 0 the property,am exclusively conlractlngwlih licensed contra re oconetru
Me prated(Sec]014,Business,and ProfesMons Cotle:The Contractor's Lke - tlo waw ;
LC.B.O.REPORT NO.
appy to an owner of property who curios or improve thereon,and waw contra r'uch
Win a cuntractods)licensed pureuont to Ute Contractors License Law.
❑1 am warrtpt unser S . ,B 8 or in l monPR MFGR.INSTALLATION SPECS.
Owner Date s I N DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby allirm under ponahy,of perjury one of the following Cecland : QV Sol/-
1 have and will maintain a Certificate of Consent to eetl-Ineure for W1 a ' nsaflon, Building
as ptovldmi for by Section 3700 of the Labor Code,for the psdormancs at the warklorw ��
penIff is 1h wan � Seismic SO
❑ have entl will melnteln Workers Campetteatlan Insurance,as required by Sectlen 3700 ofd
the Labor Code,for the performance of the work far which this parmlt Is Issued.My Workers
CompeCnsation Ins��u�r...a���nce carrier and Policy number are: wC Oast 31 Total
CanlgsTn /,.rye PuncyNo. -9 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ /
(This section need not be completed!If the permit Is for one hundred dollars($100)or lees.)
ridwork -9
I csy that In the performance
ormance of the for which this permit le(sail I shall not employ -2-6
any Person in any manner so as to become subject to the Workers'componsabon Laws of Cala- All roofs shall be inspected prior to any roofing material being
fomi0 installed. If a roof isinstalled without first obtaining an
Date Applicant inspection,I yve all new materials for inspection.
NOTICE TO APPLICANT: ll,after making
king this Certificate of Exemption, lu�oouald become Al nt understan TanIl comply with all non point
subject to the Workers'Co nsanon rWslons of the labor Code,with Such provisions or this permit ahall be deemed revoked.I ce lity that I have read Ws application antl state deet the above Inlormarlon le corrad.I epeeto comply with Na city and county ommences end state lase relating to bulldlnpconevuctbn,antl All r00}CO S C°Or better.
hereby authorize rapreeanmtivea of this cdy,to inner upon iha abovamentloned property for In
spade)purposes.
(We)agree to rave,Indemnify and Peep henniese the Cfry of Cupertino against Ilebllltles,
. jud merits,costs and expenses which may In any way accrue against avid Cary In consequence
of �egrantngoflhlepermh. SIGNATURE OF APP C 1 DAT
PRE-INSPECTION: PLYWOOD: IN-P RESS:
INSP. DATE INSP. DATE I P. DATE
TEAR OFF INSPECTION: BATTENS: of INAL:
INSP. DATE - INSP, DATE INSP.-DATE.
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY