R-6671 �g LICATION FOR CITY of CU PERTINo NUMBER R" 6671
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 7T7-3228PERMIT EXPIRES IF WORK IS NOT STARTED
WRNIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
•. BUILDING ADDRESS
p t
RESIDENTIAL COMMERCIAL _ OTHER
OWNER'S HAZARDOUS FIRE AREA
//��� I YES ❑ d yes—I understand that a Class A
NAMEl?I--41+V n 1I +` M A" - ,S—P f✓ I(,� � roof assembly is reglired
140 ❑ ldal I.C.B.O.A
ADDRESS 7 rJM✓day +� �f•• �-05 C,nZ"ec, GA- EXISTING ROOF COVERING
PHONE FS-D 33 Q _ NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
NAME �or 1� C.v C. TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP E� / S �. ST- EXISTING
PHONE 7 $ 0�O3a UILT-UP ROOF ❑
LICENSE
NUMBER O p ASPHALT SHINGLES ❑
LICENSEDIO
CONTRACTORS DECLARATION
I hereby affirm met I am licensed untler provblons d Chapter 8(commencing with Saclbn WOOD SHAKES
7000)of Dwislon 3 of the Business end pmfesslons Code,and my license Is In full force and
°I°r'" /' .SZIW INGLES �99
ucenee Creed v�� Lica NumoerO, � �+ -�AJ L .7
�w SeaS ��, OTHERFY) V ❑
Date s Code:or /
OWNER BUILDER DECLARATION PROPOSED'
I hereby affirm that I am exempt from Me Contractor's Lbense Law for the following reason.
(Sec.70315, ,improve a w Pmbaelore Cade: Arty clry or county which reprises a permit to
caretvuni ensu,improve,tleme asi or r.paa em nt that e,prior to Its issuance,aha reproves the BUILT-UP ROOF
of Me Co for such permit a Ills a(Chapter
statement that he Islicenseda Section
pursuant me provWone +� ❑
of Me ss an Prof sines Lax()hepar 8(carrurendng with therefrom
and 7000)al for Me 3 of me
euelnpee entl viclatsbne Code)or that he b exempt ntfor entl the beet for Me scantalleged ASPHALT SHINGLES
exemption.Armyf not m n of then
fon 7031.5 by any applicant for a permit eubleeln gra applicant to
e all penalty of not more men floe by empl daryessre th wag): WOOD SHAKES
❑I,m owner of the property,tImyded or offered for
wegee(Sti 7fob crompess,and
e- ❑
the work,arW he Ctnxture Is not ruenLow a offered for solo(Sec.70sA, opine entl Probe-
ebreCod.:The,and
dtissue Lew himself apply to his ow r ofplaytes,who Wlltlsa WOOD SHINGLES ❑
Improves Hereon,entl who does such work himself or mrough his own empkryeea,provitled met
such Improvements we not Intended or offeree for sale.ll,howeox,the Wilding or Pmprovement
Is sob went one year of compbtlon,the owner-Wlkler will have the burden of proving that he dw OTHER(SPECIFY) ❑
not bulla or Improve for purpose of able.).
❑1,as owner of the property,am.xclusivoy contracting with licensed contractors to construct
the prolw(Sac.7a .Business and Pmfecsbna Code:The Contractor's ucernea Lew does not PROVIDE LGB.O.REPORT NO.
app to an ownerof property who bulds or Improves Mereon,and who contracts twouch projects
with a conbactor(s)licensee pursuant to the Contractors Lic.rue l-aw. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,e 8 P.C.for MW reason
Owrror Det. APPLICATION DATE VALUATION PERMIT FEE
WORKERS COMPENSATION DECLARATION -
I hereby affirm under penalty of Wary one of the following declaration:
❑1 have and wog maintain a Cerifleale of Consent to sw4rusure for Workers Cortpeneetlon, p0 Building
as provided for by Section 3700 of ft Labor Code,for me performance of live work for which this •�
permit I bared. r f✓'�} Seismic
e have and will thepmaintain Workers f the wvetbn Insurance,I s e°required by 9ectbn 37 O ofow's
�h ebur Coda,for the psdomreroe of me work for which MIs permit le leeuatl.My Workers
compens1aItion Ireumnca carper and Policy number aro: Total
CarrlerUlf��4^�y` X;,/a � PokcyNo.WG3ctsd'ocxfi PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This secdm need not be completed 1 me pamnit is for oro hundred dollars($1 W)or lose.) /f
I cadlly,that M the periarmaroe of the work for which the permit Is baued,I e1W1 not employ
erry person 1n any manner w ee to became subject to ire workers'Compensation Law.of Gall- All roof^ all be inspected prior to any roofing material being
b"1p insta d. It a roof is installed without first obtaining an
Date Applicant insp tion,I agree to remove all new materials for inspection.
NOTICE TO APPUCANT. If,after making mb Certificate of Exemption,you should become Applicant understands and will comply with all non int
whit such provisionsoror III ps on all beaemmeerevoked.e° r cies,you moat forthwith c«rpry, source regulations. p y
I cardfy that I have read this application and state that Me shove Information Is correct.I agree p�y�%
to campy, ws with all city and county ordinances entl state larelating to Wilding construction,and All roof co" nngs to be class"C"or better.
hereby auffiwze rarepresentativesrebn
e of Ihle city to enter upon the ebo -menietl property for In-
apection
(Wel agree to°eve,Indemnity y entl keep harmlassmy the Clry of Cupertino a In°t Ileblllti.e, C
lutlggmenLe,cosh entl expenses which Trey In any way accrue against Belo Clry�n coneequenca NATURE OF APPLICANT DATE
of the granting of this penhit.
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