R-6593 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 6593
INSPECTION DIVISION PERMIT i IRATICN
'REROOF PERM _ (408)777-3228PERMIT EXPIRES IF WORK IS NOT STARTED
WTfHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
aa y •3 I w1 RESIDENTIAL • COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA-
L �q e— YES ❑ If yes ss-I understand that a Claw A
NAME ✓`� t/L ' S \�D S S I •�
NO Jyot assembly is required.
yyaL - C�� InNal LC.B.O.Y
ADDRESS _S�7 YN k' EXISTING ROOF COVERING '
PHONE
NUMBER OF EXISTING COVERINGS Oy
CONTRACTOR'SkCJ k
NAME r�1� lA {. S �!e CI r O 8 1 +`�- TO BE REMOVEDJ TO BE RETAINED
ADDRESS (J O 1 ' ''1 ') TYPE OF ROOF COVERING
CITY&ZIP \ r / EXISTING '
Q
PHONE U C)g 1 - a 2 y BUILT-UP ROOF ❑
LICENSE E]NUMBER ASPHALTSHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby aHlrtn that I am holy seal urMer provldons of Chapter 0(common ing with Section WOOD SHAKES
]000)of DivLeion 3 of the Business and Profeaalarro Coale,and my license is In lull force and
effect. WOOD SHINGLES
License Cle Lk.Number 5 ` n
— Y�3 OTHER(SPECIFY) n u
Date Cinimctor � I j
OWNER-BUILDER DEC's LicenON
se
PROPOSED L :JUN[]O 4 1999
hereby ,Bu that em exempt hos the Contractors License Law fon aha following reason.
(Sec.]0315,Business end Profosskns Coale:-Any dry or county which re,also a uirest to
construe,elbglmpmve,demolish,or repair any structure,prior to lb Issuance,eLsa requires the BUILT-UP ROOF
applicant far such permit to fila a signed statement that he Is Ilceneed pursuant to the provisions
of the Contractors License Lew(Chapter 8(commencing with Sol 1DDD)of Division 3 of Me '
• Business end Professins'Gods)or Mat he Is exempt therefrom and the 4A
for the alleged ASPHALT SHINGLES By
exemption:Any violation of Section 1031.5 by a"applicant for a permit sub eMe applicant to
e dull penalty of not more than flue hundred dollars(f 500).):
EJ 1.as owner of the pr perry,or k
ployess with wages et sol pence Ildo WOOD SHAKES ❑
Me work,and the at a is not Inor offered to sale .1 nal Pmtee-
ebru Code:The Can core Ucend rot o an property who builds or WOOD SHINGLES ❑
Improves thereon,a who does suk hl or Mro h h loyees,ptavlded that -.
such Improvement re not Intentleered r II, Me bullring or Improvement
Is told wbhln on of completionwner ullder ve th talent of proving that he dial OTHER(SPECIFY) ❑not buffo or for purpose❑I,es rot the preps ,em nocarg with"Canted conroxfore to construct
the ptalect so.1044, sss anssaiors Code:The Contractors License Law does not PROVIDE I.C.B.O. REPORT NO.
apply to en nor of pr rty who bImproves therein,and who contracts for such projects
with a conha lived pursuant to Me Contractors Uceose Law. PROVIDE MFGR.INSTALLATION SPECS.
O 1 am exema der Sec. ,B&P.C.for MIs reason
.owrwn Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm u alar penalty of perjury one of Me following declaration:
❑1 have and will malntain a Certificate of Consent to self-insure for Workers Compensation, Building13-7
d fo
as pro,rder by Section 3100 of Me Labor Code,for Me performance of the work,for which We
permit is beued. Q Seismic
11 hale and will maintain Worker's Compeasetlon Insurance,as required by Section 3100 of
_the labor Code,for Me performance of the work for which thfe permlt Is Issued.My Workers -7,Q�
Compersatbnl ura
rrbrIry nu rare: TOla ^�
Carrier — I I Policy No. 0� f?� 2 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N CQ
(This section need not be completed H Me permit b for one hundred dollars 1$100)or less.) ( 7 7
I certify that In the performance of the work far which this permit b Issued.I shall not emW oy
any person In any manner so"to become wb)ect to the Workers'Compensation Lewis of Call- All roof^shall be inspected prior to any roofing aterial being
forals. - installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
suss,to the Worker'Compensation provislots of the Labor Code,you moat forthwith comply P Y
with such pmolons or this permit sba10be deemed revoked. Source regulations
I certify Met I have reed this applkxttian anal state Met the above informal Is correct.I egmo
to comply with ell cry and county ordinances and stab levee relating to building conebucllon,and All roof coverings to be class" Or utter.
hereby aumorI representatives of Mb dry to enter upon the above-mentioned property for In-
spection purposes . \J,)
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabild[M.
ludgments,-costs and expenses which may In any way accrue against said Cary In consequence SIGNATURE OF APPLICANT . DATE
of Me gtandng of this permit.
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