R-6463 APPLICATION FOR CITY of CUPERTINO
rPE s RR- 6463
INSPECTION DIVISION PERMIT XPIRATI N
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 130 DAYS OF PERMIT ISSUANCE OR
190 DAYS FROM LAST CALLED INSPECTION.
•. BUILDING ADDRESS
aef l/ �G( e/U/I�IJ RESIDENTIAL' COMMERCIAL OTHER '
OVINER's HAZARDOUS FIRE'AREA
A/� YES ❑ It yes-I I1r1dBr8fafld that a Class A
NAME I 'r• Ha r r i roof asserrldy Is required
n /+ NO F� Irutal - I.C.B.O.M
ADDRESS 1f(7 3. . 13G 7 1�!// flue... .L r.i/,.kms%!/Ir) EXISTING ROOF COVERING
PHONE - �— NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
�; TO BE REMOVED TO BE RETAINED
NAM � f
ADDRESS p 9J/ TYPE OF ROOF COVERING
CITY aZIP �rQ c
EXISTING ,
PHONE �G��cDJ /— Icj.Z 7 BUILT-UP ROOF ❑
LICENSE ❑
NUMBER ASPHALT SHINGL'
UCENSED CONTRACTORS DECUIRATION , /,
I hereby affirm that I am greased under provisions of Chapter B(commencing with Secllon WOOD SHAKES Sb �,Vim\ ❑
]000)of Division 3 of the Business and Proleeelons Code,and my license is In full furca and -
effect. �y WOOD SHING APR ❑
License Class Le.Number I 1
d2 /3_q 9 coma OTHER(SPEA 3 I 9
Date n
OWNER-the tr CLARcense PRO D Y
hereby affirm Bu that am exempt ions the Coca: Any cry or coca Lew for the brewing rasion.
(Sec.]0315,r,mineaa ere olsh.obrmitshAiry cry or county which requires a permit to
construct,alter,such permithofe,demto file signaepelrementtate,prior to liceneta lsausnce,alas ethe proreahhe -UP ROOF
of the Co for such permit to Ills a signed r 9(commencing
comm that he Is h Section
pursuant to the prwof the
of the Contractor's Ucense Lew n or
hat a Is ex a pt t with Section the of Division 3 0l the
Business and Pricatioon f Code)or that he Is exempt therefrom and the heels for rte alleged ASP GLES
a start pan.Airyf notmo of h soon 7031.5 by arty applicant for a permit euDpdn Ihe applicant to
e dWl penally of not more then five hundred dollars(5500).):
01,as owner of the property,w my empkryeae with wages u their ads compinse0on,will do WOOD SHAK ❑
the work,are the structure Ie not Intended or offered fur sale(Sec.]06 .Business and Photos-
alone Code:The Common, Ucenae Law does not apply to an awner of property who builds w WOOD SHINGLES El
such
re
es theon,and who does such work himself or through hes own empeyeee,provided that
such Improvements are not Intended or offered for sale.If,however,the Wilding or Improvement
is sold within one year of compleron,the owner-Wllder will have the burden of forming that he do OTHER(SPECIFY) ❑
not Wild or Improve for purpose of rile.).
Decowmar of the r� ndfognnrsU�°L
the roject((Sao7 ,t4,Bnia eProoessr,Code:The ContracttosUceneeewd rot PROVIDE I.C.B.O.REPORT NO. '
apply to an owner of property who Wilds or improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractors Ucenas Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.IV this reason
0., Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
1 have and will maintain a CerMcate of Consent to seaneure for Workers ComPeneaten, BBllding9 7
as provided for by Section 3700 of the Labor Code,for the pare rachis 'ot Me work for which this So
permit Is Issued. /) 7oZ D D /
❑ have antl wasfor maithe tainpars Wnsunce f far work
yon which ce.this as required by Section DI of _ ✓C $eISmIC
,the Labor Code,for the pertarnrarxre of Ne work for which this pertnit u leeueptl.My Workers /�
CarrrQens�lon lneurence,nr rend Policy nu bar are: 0,2KRm 11 . 2 199 Total �_[„�
CanNNie°`-/•�M�'� �M icy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE N.CQ ^ ^�
(This sachem need not be completed If the permit Is for one funereal dollars($1001 or less.) 7
I certify that In the pedormence of the work for which We permit b Issued,I shell not employ
any person In any manner an as to became subject to the workers Compenaatlon Laws of Cali. All roofs shall be inspected prior to any roofing material being
orn18' installed. If a roof is installed without first obtaining an
Date Applicant inspection,,)agree to remove all new materials for inspection.
NOTICE TO APPUCANT: H,after making this CertlHpale of Exemption,you should become Applicant. and will comply with all non point
subject to the Workers Canpensadon provlslons of the Labor Cade,you must forthwith comply, pP P y P
with such provisions or this permit sholi deemed revoked. • source regulations.
I certlq that I have read this applicagon and state that the above Information Is correct.I agree
to comply with
lhdl city and county ordinances and state laws reletirgm Wilding Caulructlon,and All r O OVerlDgs tO be Cl HBr..
hereby auodze represenlalives of this city to enter upon the aDove-mentaai property fur In- C
epacWel ten purposes.
( agree to aero,Intlermity and keep heldse the City of CuperiMoep elnet lisdldiee, J+�
lucipmenta,casts ere expenses which may in any way accrue against said Clry In ccnsequerx:e SIG-NATURE OF APPLICANT DATE
• of fine granting of this penult
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