R-660211
rY
PERMIT R_ 6602
APPLICATION. FOR. CITY OFCUPERTINO- NUMBER -
- INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 ' PERMIT EXPIRES IF WORK IB NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
-
!J _ _ /
0-770
JT�J �v
RESIDENTIAL—K— COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
YES ❑ N yos— I understand Uet a Claw A
NAME j G %y /iA b✓ iC—r )
mot esseartbly is mquffed-
NO ❑ 1116111 I.C.B.O.I
O D 'S -
.EXISTING ROOF COVERING
ADDRESS
i�ro` �'— �7
NUMBER OF EXISTING COVERINGS /
PHONE !7
TO BE REMOVED / TO BE RETAINED
CONTRA 'S
C/.
NAME G
ADDRESS
�•
TYPE OF ROOF COVERING
CITY & ZIP/� •
ExlsnNG
Zy z �76 y
PHONE
BUILT-UP ROOF �y
Yr'
LICENSE
.NUMBER Z 7 Z
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed Under provisions of Chapter B (cumrfendng with Section
00 SHAKES ❑
7000) of DMMon 3 of the Business and Professions Cade, and my license Is In full force and
affect. C ?� Z
/� fl
D SHINGLES ❑
-?7
Ucanae Closed Uc. Number
Date ti'//" Contractor 6V 60l /fir
-
OTHER (SPECIFY) ❑
PROPOSED .
OWNER -BUILDER DECLARATION
I hereby affM
irm at I am exempt from the Conbectors License Law for the following resi
(Sec. 7031.5, Business and Proleeelons Code: Any city or county which requlres a perms to
contrud, after, Improve,demolish, or repair any structure, prior to its Issuance, also requires the
for such permll to file a signed statement that he le Ilc,,need pursuant to the prwfelone
BUILT-UP El
of he Contri Ucansa Law (
ofa (commencing OM Section 7000) of Dlvlalm 3 of the
Business and Prolesslons Cotle or that he Is therefrom and the basis for Me alleged
exempt
ASPHALTexemption.
Any vIol°tion of Section 7031.5 by any applicant for a permit subocte the applicant to
a ctvll penalty of rot more then Ilve hundreddollars (5600).):WOOD$HU
N 11 19991C]"gasI, D
kE
as owner of the property, or my employees with ge° as heir ode compensation, will dothe
work, and the struduro 44Is not Intended or offered for able (Sec. 70, Business, anti Profes-
sionsCcde: TheContractoesUceneLawdoesnotapplytoanownerofpropertywlobuildsor-
WOODS ❑ '
Improv, thereon, end who does such work himself or through his own emplowea, provided that
such Improvement, are rot Intended or offered for tele. It, howwer, the building or Improvement
B
Is sold within one year of compldbn,the o.sr-bullder will haw the Wrden of proving that he did
OTHER(S
not bulk or Improve for purpose of sale.).
-
❑ I, as owner of the property, am mclusivety, contracting with licensed contractors to construct
the project (Sec. 7044, Business anti Profe°ebne Code: The Contractors Ucense Law does not
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who builds or wprwas thereon, and who contracts for such projects
Mena Watractor(s)Ikamad pursuant to he Contractors Ucanse Law,
aye_
01 em exempt under Sac. ,B & P. C. for this reason
PROVIDE MFGR. INSTALLATION SPEC SA
O,,mar Date
APPLICATION DATE
VALUATION
PERMIT FEE
_
' WORKER'S COMPENSATK)N DECLARATION
y/
p/
v -2-0--Building
/IDQ
V
2" 00
I hereby affirm under penalty of perjury one of the Idiowing declar°tlon:
01 he" acrd will malnteln a Certificate of Consent to self -Insure for Workers Compene°tkn,
as provided for by Section 3700 o1 the Lobar Code, for the performance of Me work for which this
pe
permit Is Imed.
70
Seismicthe
41 have and will maintain Workers Compensation Insurance, as required by Section 3700 of
I
abor Cotl0, for the performance of the work for wi lU this permit Is Issued. My Workers
Conrpense Insurance Mer Policy
Total r
on ca andnumber are
d OZ Z791 -o
Xz
PERMIT AUTHORIZATION
DATE
Carrle �rl/f �O�✓✓ ✓ Policy No.S75R
CERTIFICATE OF EXEMPT10N FROM WORKERS'
COMPENSATION INSURANCE N.CL]
(This sectkn need not be completed It the permit Is for one hundred dollars (S100) or foss.)
oe-/gsti%Yt�IiLC,
1 cernty that in Me performance of the work for which Mle permit b Issued, I shall net employ
any pennon In any manner w safe became subject to the Workers' Compensstbn Laws of Cell-
All roots Shall be inspected prior to any rooting materal being
foml°'
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
Applicant understands and will Comply with all non point
NOTICE TO APPUCANT: If, after mating this Certificate of Exampli you should become
subject to Me Workers' Compensation provisions of the Labor Code, you must forthwith comply
with such provision or this permit shell be deemed raroked.
source regulations. -
I tardy, hat I have read this application srrd state that Me above information Is correct. ) agree
to dryand county ordnarcae ark Mate lam and
All roof t0 "G' or better.
herempyworize upon the ms ftincanspertyf
hereby authorize repreabniativae of this clry b enter upon the abww-menllonetl property for In-
ep purposes.
(We)
IWe) agree to ,eve, Indemnify and keep harmleab me,CNy of Cupertino a )net Iladlltlsa, . -
accrue
SIGNATOR APPLICANT DATE
jutlpmenta, crosb and expenses which may In arty way against said Ohl consequence
of the granting of this permlt
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