R 6588 PERMIT R_ 658
8
APPLICATION FOR CITY OFCUPERTINO NUMBER
' INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WITH
N DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
]042.1 00j Tat A_+'IAL Avj RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
/Cf t �A
� VES [-IIfyes-I understand that a OassA
ON
NAME /}(dy a s�1 roof assembly is required.
/ lJ �,(.,, NO ❑ Initial LC.B.O.b
ADDRESS (bs�( GL` � Q°O`C 1w"llLQ- a".3 EXISTING ROOF COVERING
PHONE if Og - 3s Lif 361 b NUMBER OF EXISTING COVERINGS 3L 6c ucl lfi
CONTRACTOR'S
M a ^ TO BE REMOVED Z 3TO BE RETAINED
NAME U lJ' � \7--' 0
ADDRESS TYPE OF ROOF COVERING
CITY a zip EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT S
LICENSED CONTRACTORS DECLARATION Ail
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Sect WOOD SHA ES �.
7000)of Division 3 of the Business and Professions Code,and my license Is In full force
affect' WOOD SHI S
License Class Lic.Number ���"L O •ISI•��
E (SP I ) ❑ nil
Data Contractor
OWNER-the Conn DECLARATION
License PROPOSED
I hereby affirm Bu that I am exempt from the e: Any city License Law for the finsfollowingreason.
LU
cons.70315,Business and Professions Code: Any city or county which requires a permit to
conatrucialter,orsu Improve,demolish,orrepair any ntmcWre,prior to its Issuance,also requires the BUILT-UP ROOF ❑
applicantCfer such pecan to file a signed statement that he Is licensed pursuant 000)of
the Provisionsof the
. of the ss and Prof Licence Law(Chaplet 9(commencing with Pm and 7000)of Division 3 of the 9
Business and Professions Code)or that he Is exempt therefrom end the basis for the applicant
to ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred employees
geesdollars(h wag 1:
QQ��L as and
the structure
tuneproperty,not I tended oyallered for
(as Sec.7 sole Compensation,snPrlll s. WOOD SHAKES ❑
sions Co and the structure is not amended ores not fon sale n ow 7r of Business and Proles
Ilona Code:The Contractors License Lew does not apply to an sown of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work offered
or through his own employees,provided that
such improvements are not completion,
leb n,or owner for sale. ill however,the building or Improvement
Is notsold bull or
prove for purpose
sthe owner-builder will have the burden of proving that he tli0 OTHER(SPECIFY) ❑
not build as
Improve ler purpose of sale.).
❑I,ec owner of the properry, an exclusivelycontracting Code:
T with Contractor's
otl contractors to construct
the project(Sec.7044,of rBusiness end Pt or improv Cotle:The Contractor's License Lew does not PROVIDE LC.B.O.REPORT NO.
apply m an owner of property who builds or improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
C3 em a empt untler Sac. .B&P.C.for this meson _
Owner-1 ner ""'" - - APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: —�
I-]I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building - 7
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this ''ww
permit is issued Ciro Seismic
(D have and will maintain Worker's Compensation Insurance,as required by Section 3700 of ))_ Qr
the�bor Cotle,for the performance of the work for which this permit Is Issued.My Worker's — Total /,/?,70
Compensation Insurance carrier and Policy number are:
Carrier S�Allk Policy No. 1`-(sole- 7 D PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NA.❑
(This section need not be completed it the permit Is for one hundred dollars($100)or lass.) �'�-'�'� jq
I certify that in the performance of the work for which this permit is Issued,I shall not employ
any person In any manner so as to become subject to the Workare'Compensation Laws of Cali- All roofs shall be inspected prior to any roofingmaterial being
fornia. ate}, L' '- installed. If a roof is installed without first obtaining an
Date '-�'31- 1-I Applicant IPL4" &. inspection,I agree to remove all new materials for inspection.
ecome
subjlect to the Workers'Compensation pOTICE TO APPLICANT: if,after rovisions of the llLabor Coda cate of Exemption,
mustforthwith tlbcomply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. Source regulations.
I certify that l have read this application and state that the above Information Is correct l agree All rO COVerin S10 be class Air better.
to comply with all city and county ordinances and state laws relating to building construction,and g
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes. y, 4
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, ✓✓11 5�3�
. of the gran,coats and expenses which may In any way accrue against said Clry Inconsequence SIGNATURE OF APPLICANT DATE
of the granting of thisand permit.
PRE-INSPECTION: PLYWOOD: 7 IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: 'FINAL:
INSP. DATE INSP.—DATE INSP.—DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
PERMIT R_ 658
8
APPLICATION FOR CITY OFCUPERTINO NUMBER
' INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WITH
N DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
]042.1 00j Tat A_+'IAL Avj RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
/Cf t �A
� VES [-IIfyes-I understand that a OassA
ON
NAME /}(dy a s�1 roof assembly is required.
/ lJ �,(.,, NO ❑ Initial LC.B.O.b
ADDRESS (bs�( GL` � Q°O`C 1w"llLQ- a".3 EXISTING ROOF COVERING
PHONE if Og - 3s Lif 361 b NUMBER OF EXISTING COVERINGS 3L 6c ucl lfi
CONTRACTOR'S
M a ^ TO BE REMOVED Z 3TO BE RETAINED
NAME U lJ' � \7--' 0
ADDRESS TYPE OF ROOF COVERING
CITY a zip EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT S
LICENSED CONTRACTORS DECLARATION Ail
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Sect WOOD SHA ES �.
7000)of Division 3 of the Business and Professions Code,and my license Is In full force
affect' WOOD SHI S
License Class Lic.Number ���"L O •ISI•��
E (SP I ) ❑ nil
Data Contractor
OWNER-the Conn DECLARATION
License PROPOSED
I hereby affirm Bu that I am exempt from the e: Any city License Law for the finsfollowingreason.
LU
cons.70315,Business and Professions Code: Any city or county which requires a permit to
conatrucialter,orsu Improve,demolish,orrepair any ntmcWre,prior to its Issuance,also requires the BUILT-UP ROOF ❑
applicantCfer such pecan to file a signed statement that he Is licensed pursuant 000)of
the Provisionsof the
. of the ss and Prof Licence Law(Chaplet 9(commencing with Pm and 7000)of Division 3 of the 9
Business and Professions Code)or that he Is exempt therefrom end the basis for the applicant
to ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred employees
geesdollars(h wag 1:
QQ��L as and
the structure
tuneproperty,not I tended oyallered for
(as Sec.7 sole Compensation,snPrlll s. WOOD SHAKES ❑
sions Co and the structure is not amended ores not fon sale n ow 7r of Business and Proles
Ilona Code:The Contractors License Lew does not apply to an sown of property who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work offered
or through his own employees,provided that
such improvements are not completion,
leb n,or owner for sale. ill however,the building or Improvement
Is notsold bull or
prove for purpose
sthe owner-builder will have the burden of proving that he tli0 OTHER(SPECIFY) ❑
not build as
Improve ler purpose of sale.).
❑I,ec owner of the properry, an exclusivelycontracting Code:
T with Contractor's
otl contractors to construct
the project(Sec.7044,of rBusiness end Pt or improv Cotle:The Contractor's License Lew does not PROVIDE LC.B.O.REPORT NO.
apply m an owner of property who builds or improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
C3 em a empt untler Sac. .B&P.C.for this meson _
Owner-1 ner ""'" - - APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: —�
I-]I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building - 7
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this ''ww
permit is issued Ciro Seismic
(D have and will maintain Worker's Compensation Insurance,as required by Section 3700 of ))_ Qr
the�bor Cotle,for the performance of the work for which this permit Is Issued.My Worker's — Total /,/?,70
Compensation Insurance carrier and Policy number are:
Carrier S�Allk Policy No. 1`-(sole- 7 D PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NA.❑
(This section need not be completed it the permit Is for one hundred dollars($100)or lass.) �'�-'�'� jq
I certify that in the performance of the work for which this permit is Issued,I shall not employ
any person In any manner so as to become subject to the Workare'Compensation Laws of Cali- All roofs shall be inspected prior to any roofingmaterial being
fornia. ate}, L' '- installed. If a roof is installed without first obtaining an
Date '-�'31- 1-I Applicant IPL4" &. inspection,I agree to remove all new materials for inspection.
ecome
subjlect to the Workers'Compensation pOTICE TO APPLICANT: if,after rovisions of the llLabor Coda cate of Exemption,
mustforthwith tlbcomply Applicant understands and will comply with all non point
with such provisions or this permit shall be deemed revoked. Source regulations.
I certify that l have read this application and state that the above Information Is correct l agree All rO COVerin S10 be class Air better.
to comply with all city and county ordinances and state laws relating to building construction,and g
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes. y, 4
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, ✓✓11 5�3�
. of the gran,coats and expenses which may In any way accrue against said Clry Inconsequence SIGNATURE OF APPLICANT DATE
of the granting of thisand permit.
PRE-INSPECTION: PLYWOOD: 7 IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: 'FINAL:
INSP. DATE INSP.—DATE INSP.—DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY