R-6672 S n PERMIT R_ 6672
LICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRAT4 N
REROOF PERMIT.. (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
� e /7
O O 4 C.t lr II�,Pc RESIDENT AL COMMERCIAL OTHER
OWNER'S J - HAZARDOUS FIRE AREA
CO1 YES ,❑ M yes-I understand that a Class A
NAME CO^x'yv^cis f ' S C"C U ( l V root assembly is required.
' NO ❑ Irtill I.C.B.0.7
ADDRESS �� fJ.•L�(/ Y QrV I`e56aTo.SYi''• EXISTING ROOF COVERING
PHONE ' $' 03 O NUMBER OF EXISTING COVERINGS
CONTRACTORSNAMEo�C S-Ga So..5 F� TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
� fCITY&ZIP ri O ,,Lf •n- U�,S.,S.C./�. `�s'9'
EXISTING
PHONE i�- 7 $ O 3 3O BUILT-UP ROOF ❑
LICENSE
NUMBER k� (Q S - ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affbm that I em licensed under provisions of Chapter 9(commencing wIM S W D SHAKES
7000)of Division 3 of the Business aro Proasslons Code,aro my'Ilcenae k In full force entl
mff�' SHING ❑
Loense Cleve 1 �' �q� Llc.Number �,/
Data 7—/V_F I can.", �� sMn�rt R tb_' oTH R(SP >6'6+6
OWNER-BUILDER DECLARATION n
I hereby affirm that I am exempt Imm the Convectors Umuse Lav for the following reason. PROPOSE
(Sec.7031.5,Business al Pmfesalans Code: Any city or county whop requires a permit to
conaWcl,alter,Improve,Oemdlsa,or repair anl'structure,prior to is issuance,also requires the BUILT-UP 34
epplkant for such permit to Ilk a signed statement that he fe licensed pursuant to the prorisfore"
of the Contactors Ucense Lew(Chapter 9(commencing wIM Section]000)of Dlvl4on 3 of the D
• Business and Profeea ons Code)a that he k exempt Iflstill and Me heels for the alleged ASPHALT SHINGLE
exemptian.Any vMetlon of Section 7031.5 by any epplktent for a permit subjects the applicant to
e civil penalty of not more than No hundred all($3001.):
❑l,as owner of the property,or my employees with wages as their sale compensation,wlll tlo WOOD SHAKES
tha work,and the structure is not Intended or offered for safe(Sec.7044,Business and Pmfes-
sons Code:The Contactors Ucansa Lew does not apply to an Omer of property who bullies or WOOD SHINGLES El
thereon,and who cors such work himself or through his own amployaae,provided that
such Improvements are not Intended or offered for sale.If,however,Me bull or Improvement
is sold within am year of completion,the owne"buisder will have Me burden of proving that he did OTHER(SPECIFY) ❑
not build or improve for purpose of sale.).
❑l,as owner of the property,em exclusivaly contra,ctlng with licensed contractors to construct
Me project(Sec.7044,Business end Professions Code:The Contrectore License Law dose not PROVIDE I.C.B.O.REPORT NO.
apply M an owner of property who builds or Improves thereon,ane wfo contracts for such projects
with a cantretlor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS.
❑1 em exempt under Sec. ' ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under pernary of perjury one of the folic nfj declaration: �.-s
❑1 have and will maintain a Certificate of Consent to seff4nsure for Worktl Compensation, -Building,(/-"L/—'
as provided for by Section 3700 0Ihe Labor Cade,for the performance of the work for wil this //7�ao
Permit;W leveued. IY Seismic . 6-0
lyra have and will the maintain f the w Compensation Insurance,as rmit Is d byissued.
Section 3700 of Qui—'�7�VFC7
ihB 'Labor Cade,for the perlomnence of the work for vRikt Mk permit la issued.My Workele
Compeneetlqjn Iruturence caviar end Policy number ere: - Total
Cerrlerl• (CQ ",,y z �N S• Policy No. C/G3OS��o4 PE AUTHORIZAT ON DATE
- CERTIFICATE OF EXEMPTION FROM WORKERS' _
COMPENSATION INSURANCE N.C.❑
(This Becton need not be completed It the permit Is for one hundred dollars($1 W)or lees.)
I cattily that In the performance,of the work for which this permit is Issued,I shell na!empfoY
any penman In any marmot old as to became subject to Me Workers'Compensation Levee d CaIF All roof all be inspected prior to any roofing material being
fort" ins ed. If a roof Is Installed without first obtaining an
Date Applicant in pection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after mal No Certificate of Exemption,you should became Applicant understands will I with all point
subject to the Workers'Compensaton provisona of the Lebon Code,you must forthwith comply PP s ancomply Y non
with such provisons or MIs permit shell be deemed revoked. Source regulations.
I certify Chet I have read this application and state that the above Informetlon is correct.I agree
to comply with all dry and county ordinances aM state laws relating to building construction,and All roof C Brings to be class"C"or better.
hereby authorize representatives of this dry to enter upon the above-mentioned property for In
ape(We) purposes.
(We)agree s gave,Indemnity erre keep harmless cc Cha of Ct end o agelrut Ilebll.. r T
judgments,casts this expenses which may In arty way accrue egalrret sac Clry In carreequerrce SIGMATURE OF APPLICANT DATE
of tis granting of this full
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 _ -