R-6255 PERMIT R-
APPLICATION FOR CITY of CUPER71NO, NUMBER 6 2 5 5
REROOF PERMIT INSPECTION DIVISION PERMITEXPIRA N
(408)77-I-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN IM DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
10
3 10 'a cid ��• RESIDENTIAL COMMERCIAL_OTHER
OWNER'S - HAZARDOUS FIRE AREA
YES ❑ It yes-I Inderstand that a Class A
NAME, rod assembly is required.' -
2 . NO ❑ tntW I.C.B.O.lf
- -
ADDRESS tci J"�� '�`'�''�� 'IC-.GC• q SU I - -EXISTING ROOF COVERING
PHONE 1�3Zo
�' NUMBER OF EXISTING COVERINGS
CONTRA 'S fy
NAME 1 ��� ✓�•�. TO BE REMOVED t TO BE RETAINED eA
lT
TYPE OF ROOF COVERING
clrvRazlP t°o 51 s ` - 95112
EXISTING
PHONE 1 — SGU BUILT-UP ROOF ❑
LICENSE •/L Z� Z1:3 3 ASPHALT SHINGLES ElNUMBER V
LICENSED CONTRACTORS DECLARATION
Thereby aHlrm that I am licensed under paWsbrre of Chapter a(commendig with Section WOOD SHAKES
7000)of Diviam 3 of the Buelneaa and Professions Code,and ny license Is In.lull face and
enact. _
WOOD SHINGLES
License Clew Lk.Number C�
Date— Coniracror -
AVt z I c,v OTHER(SPECIFY)
�
1
OWNER-BUILDER DECLA ION PROPOSED
I hereby aMrm that I am exempt from the Contractoes License Law for the loiloI reason.
(Sac.7031.5,Sualness entl Professions Code: Any city a county which requires a permit to
construct,alter,Improve,demolish,or repair any structure,prlor to Its Issuance,also requires the BUILT-UP ROOF l.�Opry1\
appn0ant for such penult to file a egned statement that he Is licensed Pursuant to the provisions
of the Contactors Ucanse taw(Chapter g(cor Idng with Section 7000)of Division 3 of the
• Business aa1 Protesslme Code)or that he Is exempt tfbrefrom and the basis for Ma alleged ASPHALT SHINGLES ❑exemption.Ary violation of Section 7031.5 by any applicant for a permit subjects Me applicant e
a cINI penalty of not more than five hundred cetera(55Do).):
❑1,as owner of the property,or my employees with wages as lhelr sae compensation,willco WOOD SHAKES ❑
Me work,are Me structure Is not Intend or.offered lois _ uainees entl Protea.-
slora Code: The Contactors Llc"erue Lew doee"I appy w AMII
=" em who builds a WOOD SHINGLES ❑
Inproveathermn,andwhodoe•Ouch work ttfheelfbr thou Isees,praWded that
such Improverrtm a are not Into dqd r on area .If,h a ImprovementIs Bold Morin one year of comple l aowner-wilde"MI-aveMproving that he did OTHER(SPECIFY) ❑not Wild or Improve fa purpose .)�N.�(���on�R�p❑I,asownerofMeproperty, doFA3dd7i Cad�9 toctors to construct
the project(Sec.7044,Buelne a'd PdA3dM e: nee Law does not PROVIDE I.C.B.O.REPORT NO,
appy to en owner of property ics or Improves Mareon,ae wsforsuchproiects
Mm a contractor(¢)licensed pur l to tee Contractors Ucenee PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. C.for this reason
owner ee APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury dna 01 the lolfowlrg declaration:
[:] ��I have and will maintain a Certificate of Consent to salblraum for Waker's Compensation, Building
as provided for by Section 3700 of the Labor Cada,for the performance of the work for which Mia
mis satusul.
perpR have and will maintain Workers Compensation Insurance,e r required by Section 3700 of -l� Seismic S z
the labor Code,for.the performance of the work for"which MIs permit Is Issued.My Workers
Compensation Insurance candor and Policy number are: Total ( 1
Caner Pocky No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ // n
(TNs section need not be completed H the permit is for ora hundred dollars($100)a sas.) K 'A
I cmffy that In the performance of 1ha work for which MIs permit Is Lseue f,I ahall not employ
any person In any manner so as to become Subject to Me Workers'Ca Pmsaten Lawn of can- - All roofs shall be Inspected prior to any roofing material being
forma. Installed. If a roof is installed without first obtaining an
Date - Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT:ne,after malting this Ce ificete d Exerrpdon,uy9„losrihwnnbceocome
suApplicant understands and will comply with all non'point
bject to the Workers'Com ation provisions of the Later Code,
vdh such provisions a this permit"IC.be deemed revoked. nlPy source regulations.
I certify that I have read NW appticaeon and state Met the above Information Is coram I agree /� _
to comply wws ith all city and county ordinances and state larelating to building caaiructlon,and All roof coverings to be class"6r better.
hereby authorize repraammitives of Mie city to enter upon the above-menikxaatl property for In.
spect on purposes.
(We)agae to save,Indemnity and keep harmless the Cly of Cupertino against kabllies, P�
judpmenor
s,costs and esponaes which may In any way accrue against see City In caequence
of ha gaming of MIs permit. 5IGNATURE OF APPLICANT DATE
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.ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY