R-6346 - PERMIT R_
APPLICATION FOR
CITY OF CUPERTINO NUMBER
6346 .
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-.3128 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
AD BUILDING ADDRESS
2Z(o(oO 2ZCo(oZ 7Z_1_1o6 -f `LZC.(o(o
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
`.,,. , YES ❑ 11 yes—I understand ithat a Class A
NAME — YY`C—K3(• ^�e..w ^ 5T'u'7�./ root assembly is required.
NO ❑ Ini al I.C.B.O.N
ADDREss EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'Sl '
NAME ---�'`N�2"0,A�. ��lu�n �O�•'� TO BE REMOVED TO BE RETAINED
n -
ADDRESSTYPE OF ROOF COVERING
CITY&ZIP ISGJ '� I��
EXISTING
PHONE �� ' Z5-1 3 — —7 BUILT-UP ROOF ❑
LICENSE
NUMBER «q,C'tp0/�='� a n - . ASPHALT SHINGLES ❑ ,
LICENSED CONTRACTORS DECLARA
I hereby affirm Nat I em Grilled under pmvfsb.0s f t�gter ( bung with Section WOOD SHAKES
7")of Division 3 of the Business and.Pidlai�add C � I le In lull force and
effect I V w v
1 WOOD SHINGLES ❑
License Close � � Lfo.Number 1 . .
Date ,I Cf 3 ( , Con yec OTHER(SPECIFY) t '
LowvomaeContrD gAnoN PROPOSED
hereby affirm nes em exempt from Ne e: A"ars orLicensecoup Lew for the follonacquires
ap reason. /
(Sec.70315,Business and elsh,or re Cr a y Airy city or county Iwrichssue requires a permit to
apps rug,alter,Improve,d file a , n repeat any structure,he prior to a Issuance,also reproves the BUILT-UP ROOF I�
of the Contractors
t for such permit a IIIc a agnate r 9(anent Ilial he is licenced W verso to the pro of the `y
of the ss anclPr Professions
Lew(Chapter 8 Is exa act with Section the It of,Macon 3 0l the
Business end violation
Cade)or that he le exempt therefrom and the hecto for the allegedreto ASPHALT SHINGLES
advll r Anyyf not more than
Swim 70315byany s($5W)applicant for apermit subjects the eppllcant to -
a Gvll penally of not mare then flue hundred dollars(5500).1:
El 1.as owner of the property,or my emplgees with wages as their ease corpeneeloon,will do WOOD SHAKES ❑
Me work,and the structure Is net Intended or offered for sale(Sec.7044,Business and Profes.
saons Code:The Contractor's Ucari Lew does net apply to an cevrwr of property who builds or WOOD SHINGLES El
thereon,and who rhes such work himself or through his even employees,provided that
such Improvements are not Intended or offered for able.If,however,the bulking or Improvement
Is add within one year of compaction,the owner-buckler will have the burden of proving that he dk OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,em excauacvely contracting with licensed contractors to construct
the prefect(Sec.7044,Busmees and Profesefone Code:The Contractors roans Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(a)licensee pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. B 8 P.C.for this reason
Owner Data. APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION x�
I hereby affirm under penefty of perjury erre of the fallowing declaration:
❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for Ura perlrrmenx:e of the work for which this q
permit is issued. Seismic 3 ✓O
11 have end will tattletale Workers Compensation Insurance,as required by Socifon 3700 of ��(�
the labor Code,for the peeormerlce of the work for which this permit Is Issued.My Workers I
Campaneatfon Insurance terrier aid Policy number are: V1 W L— Total 3
came, A<e—pt2A policy No. �L tJJS4A3 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(This section need not bu competed If be permit Is for one hundred dollars($100)on leas.)
I tartly that In the Performance of the work for which this perMt Is issued,I shall not emW oy
mpe
any Person In any manner w as to become subteen to the Workers'Coneetion Laws of Cala All roofs shall be inspected prior to any roofing material being
fertile, installed. If a' roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after ranking this Csrtlflcate of Exemption,you should became Applicant understands and will I with all non point
subject to the Workers'Compensation provisions of Ne Labor Code,you moat forthwith comply pP comply Y P
with such proviams or true permit shell ba aeemetl revoked. source regulations. -
I certify that I have reed this epWcefion and state that the above Information is conact.I agree
m
to comply with all city end counfy ordinances and state laws relating to bulking conalructkm,take All roof cov class V or better.
hereby demonize representatives of this My to enter upon the above-mentioned property for In-
spedlon purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino epehet IlebllNlee, I` G'
judgments,costa and expenses which may In any way accrue bet used City n consequence
I the granting of his perms. $ OF APP C DATE
• -PRE-INSPECTION: PLYWOOD: IN-PR R
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