R-6143 PERMIT- R_ 6143
APPLICATION FOR CITY of CUPERTINo NUMBER
INSPECTION DIVISION PERMIT EXPIRAn N
REROOF PERMIT - (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 190 DAYS OF PERMIT ISSUANCE OR
190 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
' RESIDENTIAL COMMERCIAL OTHER
OWNER'S - - HAZARDOUS P1RE AREA
YES ❑ If yes—I lmdetstand that a Class
NAME ; IUl/V - roof assembly is required.
NO ❑ InftW I.C.B.O.K
ADDRESS ���p + (�Qa'>• ( 1YlL7 7�X��7� EXISTING ROOF COVERING
PHONE �LXJ^ Z�—�/� Q�/.� /��/ NUMBER OF EXISTING COVERINGS
(NAMECONTC7I lXc�JCL_'+1_f`+^�Y fr/G1 ill
� � '
�.C TO BE REMOVED I TO BE RETAINED
NAME
_
ADORE
- TYPE OF ROOF COVERING
CITVdZIP�1 � �g.Gely7cS:S95iII
'N
EXISTING
PHONEOU� / ISS BUILT-UP ROOF 1 ❑
NUMBERLICENSE p 5� ASPHALT SHINGLE❑
LICENSED CONTRACTORS DECLARATION / -
I hereby,form met I em usi n ss; under fes ons of e.Chapter y(commencing with form
and WOOD SHAKES
7000)of DNielon 3 0l the Busmen ark Professions Code,end my license Is in IUA lone antl - -
BNa WOOD SHINGLES : / ❑
License��la7� Dc.Number I - OTHER(SPECIFY)
Dale contnC
OWNER-BUILDER DECLARATION. PROPOSED 0
1 hereby affirm that I am exempt from the Contractors I-
e Lew for me following reason.
(Sec.7031.5, Business and Professions Cade: Any dry or county whkh requires a permit to
onrarut,after,Improve,demollah,or repair any structure,pprio"o its Issuance,also recall"the BUILT-UP ROOF ❑
ofthCapplicant tr each permit icer to file a signed eters LpaJiJkw n tit to the prwlekxb.
of the sh,ono ors License Law co wi an of Division 3 0l the
Buelrteaa ark Protenaoim Cade at he t ter Io}�end a for the etleped ASPHALT SHINGLES
exemption.Arty Wolatlon of Secll 1.5 nib permit the applicant to '
e clwl penalty of not more men i red Ilan($500).):
D 1,as owner of the any, mploy¢ee.1. 0 penea and
PrOa do WOOD SHAKES ❑
the work,antl the f the o re Is not de r o lnen antl Pmfn- -
sbrmCod e:TheCon trectoreLk e t to err ny who wilds or WOOD SHINGLES
Improve thereon,ark who does h work hirml or through h s own n.proNtlatl that ❑
such Improvements we net Inon or offered for sale.If,however,the bulk g or am
Is sold within one year of complet n,the ownar-hudor will have ma burden o roving that he Mid OTHER(SPECIFY) ❑
not bulb or Improve for purpose o e
I,as Owner of the property, March,to construct
Vre project(Sec.7044,Business end Professions Code: a Contractors License Lew don not PROVIDE I.C.B.O.REPORT NO. NIA'
appy to an owner of property who halos,or Improves tlnereon,and who contrams for such"ems
with a contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B 6 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION OECLARATK)N
I hereby affirm under penalty of perjury we of the lo3ovdng dederetion:
F7ws /S.
I heark will maintain a Cen9kate of Consent to self-Insure for Workers Compensation, �S BUllding
as provided for by Section 370D of the Labor Caste,for the performance of the work for which ole `l—�yt1'%—')Il�JI I //J
permit Ie uanded.will maintain Workers Compeneatlon Insurance,u required oY 9eNon 3700 of 1 1— `�' 6 "O -�' Seismic _1L
me Labor Code,far me performance of me work for whkh this permit Is Issued.My Workers
Compenion Insu e ac carrier nd Polly m id r are: Total I
. Cerner r /1 Poaky No.f 3 b PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEM TION FROM WORKERS'
COMPENSATION INSURANCE N.CQ -
This section need not be completed If the Permit Is for cite hundred dollars($1 W)or Inl
I corify that In the performance of me work for whkh this permit Is leaued,I shall not
e�1 q
any person In any Tender so as to become subject to the Workers'Compensallon Laws o1 Cell- - , All roofs shall be inspected prior to any roofing material being
fcrna� installed. If a roof is installed without first obtaining an
Date Applicant inspection,l agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should became Applicant understands and will comply with all non point
subject to me Workers'Compensation provisions of me Labor Code,you must fordwith comply AAP P Y P
with such provtsbne of this permit all deemed revoked. source regulations.
I cenity,that I have read mu application and state that the above Information Is correct.I agree
. to comply with all city end county ordinances antl stare laws relating to bulldog conatrunon,and All roof coverings
stto�bee class or better. �Z
herebyn part ize representatives of mts tlry to enter upon the above-menUcnetl property for In. r/'; al, `^'✓", '�YY k.W�
hereby purposes. /{,y
jWe)agree to save,Indemnify DAM keg harniesa me City of Cupemno aoVital facilities,
Judgments,caste and eapenne which may an any way accrue against said City n connquenca S SIGNATURE OF LICANT DATE o
of gmntlng ECT 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY