R-6591OFFICE COPY
PERMIT
R 6591
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRA N
REROOFPERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
-
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
//A��
YES [-] H yes — I understentl tlmt a Class A
NAME L J FLi WP 1 C7 / ] rroof
ass arnby is required.
_
NO S/ Initial I.C.B.O.11
EXISTING ROOF COVERING
ADDRESS co 00 bit.
-
PHONE 20 52
NUMBER OF EXISTING COVERINGS I
TO BE REMOVED I TO 8E RETAINED $�
CONTRAI�C�OR'/$��
NAME ! �ICIA iC`iFi��O F I AYre
ADDRESS //��� nn n
TYPE OF ROOF COVERING
CITYazIP 45C.o�N�EAtC/4L �T, S?�.
EXISTING
PHONE
BUILT-UP ROOF ❑
LICENSE
NUMBER 7 S 119 1
ASPHALT SHINGLES ❑ -
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter B (commencing with Search
WOOD
7100) of DMsen 3 of the Business and Professions Code, and my license 15 In lull force and
effect.
WOOD �T(1�'��ucenme
Clave C-�9 uc. Number1_'Date
CodraclorOTHER1999ONTJER
JHIN
BUILDER DECLARATIONPROPOSE2hereby
affirm that em exempt ism the Contractor's uconue aw for the following reason.csec.onst
7031.5, Bumpro a end Prolh, a
Code: Arty dry or county which squires a permit toconscantfolter,improve,demolish,nd
rep eny to Its
BUILT-U❑of
mentrthatheprior
staor
t far etch pwen to Ills a signed licensd! pursuantelsorerluiresthe
that he Is I{ce ptreueof to the prwof
r 9 (comm
the C (commencing with Section
theof the Contractors Lkenee Lew (Chapter
ctio
of DMeen 3 0l theexample
ark Proh Me
Code) or that he la exempt therefrom end the baee er the alleged
ASPHA
lotion of
exemption. Arty violation of 7031.5 by any applicant for s Permit subjecs the applicant to
to
e ckAl penalty of not more then Ilya hundred collate ($500).):
than five
WOOD SHAKES
I, as owner of the property, or my employees with wages as their sob compensation, will do
- ❑
the work, and the structure is not Intended or offered for sale (Sec. 7044, Business anBPmtes-
sions Code: The Contractors License Law does not apply to an owner of property who hullos or
WOOD SHINGLES El
thereem on, and who desuch work himself or through his own employees, providetl that
s ich Improvements are not Intended or offered for sale. If, however, the Wliding or Improvement
-
Is add within one year of completion, the owner-Wilder will haw Me burden of proving Mat he do
OTHER (SPECIFY) ❑
not build or Improve for purpose of male.).
❑ I, as Amer of the property, em exclusively mntmm g with licensed contractors to construct
the project (Sec. 7044, Business and Professions Gke: The Contractors License law does not
PROVIDE I.C.B.O. REPORT NO.
appy to an owner of property who build@ or Improves thereon, end who contracte for such projects
with a contmctogm) licensed pursuant to the Contractors License law.
PROVIDE MFGR. INSTALLATION SPECS.
E]I em exempt under Sec. ,B 8 P. C. for this reason
Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
/
I hereby affirm under penally of perjury one of the following declaration:
❑ 1 have and will melnsln a Certlficate of Consent to sell-Insure for Workers Compensator,
er Section
Building
as provided by 3700 of Me Labor Code, for the performance of the work for which this,
permit is Issued.
o
VN�eiim9!
>
FA 475.EO
C]I have and will maintain Workers Compensation Insca urenas required by Season 3700 of
Labor Code, for the performance d ormancthe work for which this permit is h
-lithe pe My Workers
$eISfT11C -/
/1 9®
Comperoetbn Insurance carrier and Policy number ere:
TDta Iated.
tt/r
Carrier zust ICN Policy No. —5
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' -
COMION INSURANCE N.Ca
Im
(Thio section need not be competeded it H the pwmff N for one hundred dollen (f1o0) or lees.)
r
ceNty that In the performance of the .cork for which this permit Is Issued, I shell notertp
m
any person In any mannw w as to becoe sugect to the Workers' Connomnsedm Lewy of Ca1IF
All roof^ shall be inspected prior to any roofing material being
fornix.'
%%��--,�
installed. If a roof is installed without first obtaining an
, �����
Date 1oLs/i Appllwnt a ifam�Y�4 94me
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, after making this CertNicete Ff Exemption, you ahould became
Applicant understands and will cos hh�� with all non int
pp p'y
aubject to the Workers' Compensation provlslons of the Labor Coda you must lorerwlth comply
with such provisions or this permit ahoiQbe deemed revoked.
.
source regulations.
I certify that I have read this appicetlon and state that tls above Informatlon Is correctI agree
to coney Mth all city and county ordinances and state laws totaling to Wilding construction, and
All roof Coverings to be class' or better.
hereby authadae representatives of this city to enter upon the above-mentioned property for In.
spade) purposes.
(We) agree to save, i and hay a the Clry Cupertino e,Idnat liabilities,
eremnity
judgmenUit, mayI cold Ci
Inas and expertaea which may In any way accrue against seltl ay) consequence
y ori
`T
SIGNATURE OF APPLICA DATE
gran
of the granting of this pertNt.
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY