R-6326 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 6326
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN life DAYS OF PERMIT ISSUANCE OR
• 1W DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/`�
T /rte_
I I S v '� RESIDENT AL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
r
NAMEa C./I (t (.V YES EJAyes—IuMerstand thatClassA
roof assembly h require .
Intl
NO ❑ IrYtlal LC.B.O,d
ADDRESS ` o �jv' _I /h firp- EXISTING ROOF COVERING
PHONE OO T.f - l D O D . ' NUMBER OF EXISTING COVERING I
CONTRACTOR'S //•�a ^/ _ . = ✓//
NAME
I�L�CSr y (ADO Y•� TO,BE REMOVED TO BE RETAINED
ADDRESS q TYPE OF ROOF COVERING
CITY&ZIP
M,7- V i ft'l� 7 t/ / ^7 EXISTING
PHONE /�b•�) 10�_ �7 Z C� BUILT-UP ROOF
NUMBER
ASPHALT SHINGLES
NUMBER ❑
DCENSED CONTRACTORS DECLARATION
I hereby affirm met I am Ikensetl under provisions of Chapter 9(commencing win Section WOOD SHAKES ❑
)000)of Division 3 of the Business and Professions Code,end my license U In full force end
effect. 55
2 L/� WOOD SHINGLES ❑
License Claes Uc.Number . J ` 3
Data _ contractor Ndu G(�LC�r�-y OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm)het I em exempt from me Contractors License,Law for me following reason.
(Sec.7031.5,Business end Professore Code: Arty city or county which requires a Permit to
construct,eller,Improve,demolish,or repair any shrcWre,prior to Its issuance,also requires the BUILT-UP ROOF Lamy/
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
of me Contractors License Lew(Chapter B(commencing*Hh Section]000)of Division 3 of the v
• Business and Professions Code)or met he Is exempt morefmm entl the basis for the affil .ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penally,of not more than live hundred dollars(5500).):
❑I,as owner of to property,or my employees wild wages as their sale compensetion,will do WOOD SHAKES ❑
me woM,and the sMuclund U rut Intended or offered for sets(Sec.7044,Business and Profs-
stone Code:The Central License Lew does net appy to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale,If,however,the bulking or Improvement
U sold will are year of completion,me owner-bulkier will have the burden of Moving met he dk OTHER(SPECIFY) ❑
not build or Improve for purpose d We.).
❑1,as owner of the property,am exclueivey contracting with licensed contractors to construct
the pro)ect(Sec.7044,Business and Professions Code:The Contractor's Ucenae Law Rose not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bulks or Improves,thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to me Contractors License Law. PROVIDE MFGR. INSTALLATION SPECS.
❑1 em exempt under Sec. a&P.C.for this reason
owner Date
WORKER'S COMPENSATIPN DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm ubuer penalty of perjury one of me following declaration:
❑I have ebu will maintain a Cenigcate of consent to sell-Insure for Workers Compinuatka, Building
seprovxled for by Section 3700 OI the Labor Code,far the performenca of the work for which mU /.7sr9 / ?90
as pro U Issued. / 7
1 have and will maintain Workers Compensation Insurance,as required by Section 3]00 of Seismic
Met Labor Code,nor this performance of the work for which mU permit Is Issued.My Workers
Compardia xh Insurance canter entl Policy number are: G Total
Carder 40_ 1 irC%--' PoicyNo. Jrb�� PE TAUTHORIZATION DATE
- CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C{] ��
(Tits section need not se completed If ire permit U for one hundred dollars($100)or less,) VY
I certify Chet In the performance of the work for which this permit is Issued,I shell not employ
any person in any manner se as to become subject to me Workars'Compensation Lawn of Cali- is shall be inspected prior to any roofing material being
form. installed. If a roof is installed without first obtaining an
Fa„ _
Date 5`1)-r/9 Applicant �-�X��--- inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,ever mak this Certificate of Exemption,you shouw become Applicant understands and will comply with all non point
subject to me Workers'Campecatio
un prowil of the Lobar Code,you must formwllh comply
with such provUlons or this permit shall be deemed revoked. source regulations.
I codify that I have read mU application ark state that me above Information Is correcr I agree
to comply wild all city entl county ordinances and elate Uwe relating to building carurructian,and All roof COvering6,to be Claes"C"or better.
hereby euffrai representatives of this dry to enter upon the abo e-mentloned Property for Ise
spection
(We) purposes. 17
(we)agree to save,Indemnity entl keep harmless me City of Cupertino y Inagainstcon sequence, p7 —
)u marts,costa and expenses which they in arty way ecwe egelrM eek Dry in consequence SIGNATURE OF APPLICANT DATE
• o!1 aOrECT of this 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
OFFICE COPY
FROM CRSTO ROOFING PHONE NO. : 650 961 2611 May. 113 1999 02:23PM PS
.°..R Dun..... Y " .E..., ........ .A. .......E.,... O . .. .... : . . ... E.....A'... ,.T ,
DATE(MWDDI
A j(MMDDITY)4NRA
- CNC
:i
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Risk Svcs Inc of No . Cal , HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Ono Market ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Spear Street Tower Ste . 2100 COMPANIES AFFORDING COVERAGE
Son Francisco , CA 94105 COMrANY
415-543-9360 A Legion Insurance ,Co
([UHp'ANY
Costo Roofing Inc .
1938 Old Middlefield Way
Mountain View, CA 94043 -A
'
C.OLDANY
D
", x. .Z'Mrr:�. tits {
THIS IS TO CERTIFY THAT THE POLICIES OF INSUR ANCEUSTEDBEL,O W HA V 6 LEEN ISSUEb 10 THE INSURED NAMED AGO V E FOR THE POLICYPERIOD
INDICATED,NOTWITHSTANDING ANY REOUIREMENT,TFRMORCONDITIONOF ANY CONTRACT OROTHEROOCUMENTWITHRESPECT TO WHICHTHIS
CERTIFICATE MAY GE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 19 SUBJECT TO ALL THE TBRM9,
GICLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE.BFFN RRDUCRO BY PAID CLAIMS.
wl T1TNl OF IMSVRANCE POLICYNUMaEA POLICY EFFECTIVE POLICY SXPIPATION LwYrts
LTA, DAT!(MAIADTYY) ! DATC(MMIDDIVY)
I
! GENERAL LIABILITY GENERAL AGGREGATE /
j COMMF,PCIALGENERALLIABLITY rRp1UC.TS•COLR'/OP AOG 3 ,. ., ..
CLAIMS MADE n OCCUR PENSUNAL b ADV INJURY 7 ..
i
OWNER'S S CONIPACIORS I'POI i EACH! U
OCCNHENCE - f —
FIRE DAMAGE IA.,one Tire) 1
ACO EMP (A Y We penes) 3
AUTOMOSLE LMaLRV
CTtMBINEft $INnI F, _LIMIT i "
ANY AUTO
ALL OWNED AUTOS : flOD4Y INJURY 1 .
SCHEDULED ADIOS IPer Mnml
MIRED AV70T BLKIILY IALR,AY
1
MCN-OV44ED AUTOS ltfr Asiernl7
PROPERTY DAMAGE T
I I
CARAGELIABLHTY AUTO ONLY • EA ACCIDENT s
ANY AUTO OTHER THAN AUTO ONLY;
r.. EACH ACCIDENT 3
J AGGREGAT! f
EXCESS LMOLRY G /. EACH OCCUftNCe...—. _
r WDPELU FORM / AGGREGATE 1
I OTHER THAN UNSIIELLA FOKM _..—
WORKERSCOMPENSATIONAND �' STAT13MY LIMITS
A WC 10S600B2 7/01/98 7/01/99 EACH N _ s _1000000
THE PROPRIETow IHcy DISEASE -.J ICT"1- f 1000000
PARTMERS/EXECUGVE /U . . . _, .. .
OFFICERS ARE: EXC'L DISEASE EACH EI�'LOYEE ,3 1000000
OTHER
I
.I
N OPO IOM L A I M IV UP AL M
RE: License 9397223 (CASTO ROOFING INC. )
RANCE�LARION .r t JTC . r ,iS v+qvx "«..1 7.1.
SHOULD ANY OF THE ABOVS DESCRIBED POLICIES OE CANCELL90 ■VOR! TIIE
EXPIRATION DATE THaREOF, THE ISSWNO COMPANY WILL ENDEAVOR TO MAL
Contractors Stite License 30 OATS WRITTEN NOTICE TO THE CERTIFICATE 400914 NAMED TOTNl LETT,
Board BUT VALUAC TO MAL SUCH NOTICE!MALL IMIOaa NO OBLIGATION OR LIASLIIT
P.O. BOX 95926 Of A MD UP2N TH! ►AN V, ITS AGENTS ON RCIRCSEMTATRES.
Sacramento , CA 95626 7A (—DnEPR937.TI Y 833760000
.�LGOF.l1a:�fii00,010