R-65750
PERMIT R_
6575
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (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
QJ r L�
RESIDENTIAL X COMMERCIAL OTHER
OWNER'S -
HAZARDOUS FIRE AREA
—_
VES ❑ Ryes-Iunderstarcllhata ClaasA
NAME �1 „q -�ki✓� G
roof assen"y is required.
NO ❑ InIial I.C.B.O.R
�'�'�'
EXISTING ROOF COVERING.
ADDRESS-
I
PHONE ZS Z 3
NUMBER OF EXISTING COVERINGS
'
O
CONTRACT 'S
(^/ yn
TO BE REMOVED TO BE RETAINED
NAME-l•G/./O/-1_a�T�/
/x,��l-
A 0 /�/p
ADDRESS i/i•��(i!/)7W>2W K�I7 'TWCO LL[.GY /x/
-
CITY 8 ZIP
TYPE ROOF
/Q I G
EXISTING /�-�
1
6J% 73 -(3
D {
PILO 23
BUILT-UP ROOF JUN 1-,11 ,1999 U .
J
jBy
a
-
LICENSE
NUMBER 00
ASPHALT SHINGLE ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 8 (commandng wits Section
WOOD SHAKES
7000) of DMsbn 3 of the Business and Professions Code, and my license isin full force and
effect.
�
WOOD SHINGLES ❑
Lkaree Cleo Z� Lic. Number v
/ q
OTHER (SPECIFY) ❑
Date Contractor
OWNER-&U1DER Dtors
hereby the UcTI
Bu rhes em exempt from the Contractor's Lew for the following reason.
(Sec. 70315, Business and Coda: Any dry
PROPOSED
or roue
a
, p county which requires a permit e
piste, or re phortnse l nsuarfes.pursuant alsoe
BUILT-UP ROOF "
suImprove,tlfilea,ordstaenyetrucbre,
applicancc�stt for piresihe
of me Contractor's Ion such permit b Ills a Clhapt statement that he Is I Sectio pursuant to the pro of the
of ire andProfessionserofwfin Section me b of for the 3 0l the
end Professions Code) or Net he le exempt
Business ofUwnso Law (Chapter 0 Is exempt and He bests for she atlepetl
ASPHALT SHINGLES
exemption. ant for a
ex n of Section 7031.5 by eery eppllwnl for a permit subjects the eppllcanl to
exemption. Artyf
e dull peneffy of not more Than five bundrnd tlolpsro
not m
He
WOOD SHAKES ❑
❑I, as miner of property, or my employees with wages as their vole compereetbn, will do
me work- and the structure is not Intended or offered for sate (Sac. 7044, Business end Protea -
alone Code: The Contractor's Lbenm Lew does not apply to an owner of prperty who bullde or
WOOD SHINGLES ElImproves
Hereon, entl who dose seff own employees, work Nmor through his owemployees, provided the;
each Improvemenla ere not Intended or offered for We. If. however, Ne building or Improvement
Ie
U n A
a
sold within re year of completion,meowner-0ulldar will have the burden of proving that he did
OTHER (SPECIFY) ElEj {�V
not build or Improve for purpose of sale.).
I, as owner of the property, am exciusively contracdwith licensed cm1ractors to construct
the proled (Sec. 7044, BuMnees and Professions Code: Tne Contractor's License Lew dose not
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who bullds or Improves thereon, end who contracts for such projects
with a contractor(s) licensed pursuant to Ne Contractor's Llcenw Lew.
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 em exempt under Sec. ,B & P. C. for this reason
Owner Dere
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
13
Building
I hereby affirm under penely of perjury one of the following declaration:
❑ 1 have and will maintain a Certificate of Consent to wlbinsure for workers Compensation,
as; provided for by Section 37W of Me Labor Code, for the performance of He work M which INS
perms le t"and
/ o
z/�g9
D
eve end will malmainport Workers Insurers, 9e required by Section 3700 of
!
F,v00
Seismic _ o
f mew work
Ih ebor Code, for the pedormarke of Ha work for which His permit Is Issued. My Worker's
for
-
/ 3 7 g
ompensatla�n I.ns r '`��,carrier end Polby number are:
Total ( r
��`^/!
Carrier .YL�L7u Policy No. -5.
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
�--�
\( 0
COMPENSATION INSURANCE N,C.0
(This eacllon need not be completed 0 Ne permit is for one hundred dollars ($1 W) on lees.)
I certify that In the perlormance of Bre work far which this permit Is Laaued, I shag non employ
All roof^ shall be inspected prior to any roofing material being
any Person In any mender w ee m
to became subject to me Workero' C mdcye soslon Laws of Cell-
forms.
installed. If a roof is installed without first obtaining an
Date 4,�Ii4fApplicant _!/
inspection, I agree to remove all new materials for inspection.
Nonce o APPucANr: Ir, ener making mIe carp ate of Exemption, you mould became
subject to He Workers' Compensation provlslons of the Labor Code, you must forAhwMh comply
Applicant understands and will comply with all non point
pP P Y P
Min such provlaons or this permit ahalQbe deemed revoked.
Source regulations.
I cartlfy that I have read Hls application and slate Hat He above Inlormatlon Is correct. I agree
to comply with all city am county ordinances and state laws relating to bulldIng construction, am
All roof coverings to be class Or better.
hereby authorize repraaentetivas of NIe city to enter upon the above-mentioned property for in.
spectbn purposes
/
(We) agree to save, Indemnify entl keep hermleva ma City of Cuperdrto against Ilabifitiea.
Ca
judgments, coups aml experwe i which Trey In any way endue against said City In conwpuesce
SIGNATURE APPLICANT DATE
of the granting of We 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION