R-6462 PERMIT R_ 6462
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
_ WITHIN 1BO DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM UST CALLED INSPECTION.
BUILDING ADDRESS r,�1 / �//
t 3G � �+-�Q� Y �� RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS
f/�. {�/ HAZARDOUS FIRE AREA
NAME,V`�� /� � ✓1'SP^ 6 G�-Ll r)'1 VES ❑ ry��Dn ity is reqand that. Class A
,,/ bIY is required.
NO yy Initial LC.B.O.N
ADDRESS CX�I.j 44- (fit L G dJ r EXISTING ROOF COVERING
PHONE D 7p� NUMBER OF EXISTING COVERINGS
CONTRACTCA _
TO BE REMOVED
NAME TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP—I(- EXISTING .
PHONE 4Il - BUILT-UP ROOF �l_
LICENSE G - n
NUMBER O oZ- ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION '
I hereby affirm not I am licensed under provisooe of Chapter 9 mmmendng wllh Section WOOD SHAKES '
7000)of Divelon 3 of the Business al Professions Code,and my license Is In full force and
effect }^[' WOOD SHINGLES ElLicense Clava ` Lic.Number
I-V
Data Cantreel« Q OTHER (SPECIFY) El
from BUILDER DECLARATION PROPOSED
1 hereby affirm that 1 em exempt from the e: Any city Dconue Law for the fallowing meson.
(Sec.7031.5,Business ere Professions Cade: Any dry p county which requires a permit to -
rolicant,after, himprove,to file asigned or statny ement
thate,Is lorto its nsed!prsuant alsto
he provisions
lres Meisions BUILT-UP ROOF ❑
of Me o for such pUctur to Ills a(Chapter
uetemenr that he le Iberoetl pursuant to the pro Of nor
of Business;
ContractorDcenee Lew(Chapter 9(commencing with Section 7000)of Dfor the 3 0l the
•
exemption.
antl Professionallotionof Code)or thet he b exempt therefrom and rhe heels for the alleged ..
exemptlen.Any oblation of Section 7031.5 by any applicant for a pemYr subjects Me applicant to
a civil penalty of rat more than five hundred dollars($500).): 5THEFRI
//\,\,_
I,as owner of the property,w my employees with wages as their sole compensation,will do �H S ❑
the work,and Rha structure Is not Intended or offered for sale(Sec.7064.Slianas and Protea-
ebnaCotle:The Contracloes License Law does rot apply to an owner of property who builds w $HINGLEO�+,nn ❑
Improves Marson,and who does such work hmaetl or through his own timpani provbed Thar R 1 G IJ99
such Improvements are not Intended or offered for cele.If,hammer,the bulking or Improvement n 1
is sold within one year of completion,the owner-builder will have the burden of proving that he did (SPECIFY) ❑
not build Or Improve for purpose of sale.).
1,as owner of the property,em exclusively contracting with licensed contractors to construct
(Sec
the project .7066,Business and Professions Code:The Contractors License Law does not WUM B.
I C 0R
Owner FPnRT Q,
apply to an er of property who builds or Improves thereon,and who contracts for such projects M�
with a conrrector(s)Iicerral pursuant to the Contractors Uceroe Law. PROVIDE MFGR.INSTALLATION SPECS
O
❑1 em exempt under Sec. ,B&P.C.for Mla reason
Owner - Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: G�Ly�'] /�,�
Q 1 he"and will maintain a Cerci tate of Consent to seUansure for Workers Compenaation, 9 1' / BUllding C
M provided for by Sectlon 37W of the Labor Code,for Me periwmence of rhe work for which this
Permit Is veued. Seismic
❑ have ere will maintain Workers Compensationentfor Insurance,this as required by section 3700 of
the Labor Code,for One pedwmance of rhe vywk for which Ihle permit V issued.My Workers
Comperoatbn lrour corrler an[d!jlcy number are: �i/ Total
Cwrler4`� ^•� 1-�-40 Policy No. ' 3i PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTQN FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(This section need not be correlated U the permit Is for one hundred dollars($100)w leve.)
I certlty that In the pedminumc a of the work for which this permit is Issued.I shelf net mmp by
any person In any manner se,Me to become subject to the Workers Compensation Lowe of CAIF All roofs shall be inspected prior to any roofing materiel being
tennis. installed. If a roof is installed without first obtaining an
Date Applicant - inspection,I agree to remove all new materials for inspection.
NOTICE to TO APPUCCC�omponfi provissbro of Mg flys e I lona r Cooempu must forihwl�h comply Applicant understands and will comply with all non point
Subject to the Workers'
with such provisions or this permit shall be doomed revoked. source regulations.
I sanity Net I have read this application and elate that the above Informetlon le correct I agree
to comply with all city and county ordinwues and state levee relating to building conetructlon,and All roof coverings to be clas or better.
hereby euthodze representatives of this dry to enter upon the above-mentioned property Por Iri
speclbn purposes. }�
(We)agree to veva,Indemnify and keep harmless Rha Dry of CupeNlno agelrot Ileblltlae, ft O'vi T
an
judgments,coats and expenses which may In wry,way accrue against Will In consequence
of the gaining of permit SIGNATURE OICA DA
• 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