R-6272 PERMrr
APPLICATION FOR ' CITY.OF CUPERTINO NUMBER R" '6272
INSPECTION DIVISION PERMIT EXPIRATION
. - REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 GAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
CO
1
III4o Cry Apwl criC 1 AUE RESIDENTIAL COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA
l`2
- YES 0 If yea-I understand that a Class A
NAME l.� W r. '' . roof asserHNy is required. .
NO C Initial I.C.B.O.If
ADDRESS /�✓Iiiii4-b ,�C.1-1ApU,7t /L� Q(„qC,� EXISTING ROOF COVERING
PHONE `'r6 Iet*& '�� N, NUMBER OF EXISTING COVERINGS I
CONTRA(�/,TOR'S �/
NAM EL-r-•C7IOAY;JAN GG L-01 N)6, ,I l • TO BE REMOVED TO BE RETAINED
�f'7
ADDRESS a TYPE OF ROOF COVERING
.. CITYB ZIP ✓z-.1Z L\W-0L N Mt< . .g g5iZ5
\ EXISTING _
PHONE�� ) 44°0-o&il BUILT-UP ROOF ❑
LICENSE �36 ASPHALT SHINGLES
NUMBER 'ms' s r ❑ -
LICENSED CONTRACTORS DECLARATION .
I hereby affirm that I am Ilcensod undx prorislons of Chapter 8(commencing with Section WOOD SHAKES
7DX7)of Division 3 of Me Business end Professions Code,and my license is In full force and
eHac1' C�7an.1 ' - WOOD SHINGLES ❑
license Class Dc.Number ,
Date 11—fil Contractor. NAt�Aey� C�aWfI OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby alllrm Mat I am exempt Ircm the Contractors Dcense Lew for Its following reaean.
(Sec.7031.5,Business,and Professions Code: Any city or county which requires a permit to
construct,eller,Improve,demotion,or repelr any structure,pp Ior to m;Issuance,also required the BUILT-UP ROOF ❑
applicant for such permit to He a signed statement that he b Ikansed pursuant to Me provisions
of the Conncto(e License Law(Chapter a(commendnp with Section 7000)of Divu on 3 of the
Business and Professions Code)or that he is exempt therefrom and the basis for Me alleged ASPHALT SHINGL
exemption.Any vbleeon of Socran 7031.5 by any appl cent for a permit subjects Me applicant to
a dull penalty of not more than Ifve hundred dollars($500).):
C]1,as,owner of the property,or my employees with wages as their sole wmpematlon,will do WOOD SHAKES
the work,ark the structure Is not Intended or offered for seta(Sec.7044,Business end Prefer-
slonvCoca:The Central license Law deed net apply to an owner of property wvho oulltle« WOOD SHINGLES
Improve thereon,and who does such work himself or through his owrn emploiees,Ww ked that
such Improvements ere not Intended or offered for sale.If,however,Mlltling e buor Improvement
is sold wt-In one year of completion,the owner-bulder will nave the burden of proving that he did OTHER (SPECIFY)
not build or Interore for purpose of sale.). q
❑I,m ormerd tit property, n rectory to constnIt - \�
the pmloct(Sm.7044,Buslne ,Prolessl erne fired nee Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property buU1le or lrrr rear, who for such pmlects
with econlrectoga)Ilceneed pun tome' tre re ucene Lew PROVIDE MFGR.INSTALLATION SPED
❑Ism exempt order Sec. .C.for this reaeW
I 1
°"ns,` at
WOE 'S COMPENSATION DECIARATI APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty perjury one of the following emanation: /
have and will maintain a artyy to of Consent to self-Insure for W is Com nsatlon, Building
ao p❑rwfded for by SeNon 3700 IFI bcMaAsdorrtwnos h work forwhkh this � s' -
permlldidwea. lZ 6 /� Seismic
®I have and will themaintain Workers f the work
Insurance,as required by Section 3700 a
the Labor Code,for the performance of the wvmk ra which role permit is leeued.My Wor e
Compersatlon Insurance tattler anti Polley num0er are: Total
T
Carrion g r �'6 (rVNij Porky No. (� � � PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N,C.I] o
(this section need not be completed If the permit Is for one hundred dollars($100)or loss.)
1 tardy that In the performance of the work fon which this permit is Isool I mall hotemploy
arty person In any manner so as to become subject to the Workers'Compensation Lewd of Cal All roofs shall be inspected prior to any roofing material being
fort° 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: 11,after making thle Conical of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compenetkn provisions,of the Labor Code,you must forthwith complypP P Y P
with such prwblons or this permit shall De deemed revoked. sours egulations.
I Inertly Met I have read MIs application and elate that he above Information is correct I ogre -
tocornerwllhallclyandcountyondlrtiandstatelamrelating to bolldng constmction,and Allr CO rings toss or better.
hereby aumodze representatives of this city,to anter upon the mcmantionsd property for Inn
spedfon purposes.
(We)agree to save,Indeml and keep harrnlees Me City of Cupertino apalret IlabNltie, -
Judgments,costs and expenses which may In any way accrue against deal Cry In caneaquerce Tj A URE OF APPLICANT DATE
of the granting of We perMt.
( PRE-INSPECTION: PLYWOOD: g IN-PROGRESS:
INSP. DATE INSP. C 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