R-6606 PERMIT R_ 660
6
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRAT10N
REROOF PERMIT (408) 777-.3228 PERMIT EXFIRESIFWORK ISNOT STARTED
' WITHIN 180 DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS
180 DAYS FROM LAST CALLED INSPECTION.
/ /
l5's 7 46Lv v/ RESIDENTIAL✓ COMMERCIAL OTHER
NER'S /(n r HAZARDOUS FIRE AREA
` ! /�'e IL /SF2 YES O' (lyes—Iumdongencithata ClamA
NAME �I assemblytis required.
NO ( Initial I.C.B.O.N
ADDRESS(,(15�~ EXISTING ROOF COVERING
PHONE / �� `S a S NUMBER OF EXISTING COVERINGS
CNAME f'ONTRACTOF O`/� ��rrr ..F-`
✓ , / / ����ti S TO BE REMOVED TO BE RETAINED
�����_
ADDRESS TYPE OF ROOF COVERING
C1TYa ZIP /3 S�,r '/�NOLrQ WA c.�'9N tTQS�
S//L EXISTING
PHONE ��� Z7 9 Z 33 Z BUILT-UP ROOF ❑
UCENSE
NUMBER o/ / S ASPHALTS It7LES[,��
/�
LICENSE CONTRACTORS DECLARATION (1
1 hereby affirm that I am licensed under proWloha of Chapter a(commencing with So WOOD SHAKE
7000)of Division 3 of the Business and Prole ul Cade,and my license Is In lull b d, u
erect' WOOD SHIN �LESJUN 1 4-1gg�
Ucense Claes e-3? Lie.Number �6/!�s��//
Data / 9 Contractor [/C� /�-0o//N4 ,_rY/={gy}T_JHpOE,RE(DSP �IFY) ❑
OWNER BUILDER Dtors TION , lay
hereby eHBu that 1 em exempt from the aanAnycity License Lew for the follovires ag nmat to
(Sec.7031 b,Business and Professions Code: Arty cry or county Iwhichssue requires a permit to '
applicuct,char,Improve,to file esigned vapor eny stMat he prior to Ib ISa rsuant also requires the BUILT-UP ROOF ❑
0t the o for eudU p icer to Ola s haptr 9(co ant inch he t licensed pursuant of
iha prp of Me
. of the ss ancctera License coo(Chapter a Is enerniel with Section]000)of Dfor 0.301 the
Business orb violation
Cade)or that he le exempt therelmm and the beefs a the alleged ASPHALT SHINGLES
axamptlon.Anyryf W m ofhe We hundred
tryany spplfoanl bra permit subjects Me applicant to
a civil penalty al rot more then IWa hundred W liars($500).):
❑I,as owner of die property,or my employem with wages as their sl compensation,will do WOOD SHAKES ❑
the work,and the structure is=Interned or offered for Bela(Sec.7014,Business and Proles-
Im owns es Code:
and who does�wwororkdf�netl oeptl nigh nb own of Property
prroovlee11e Met WOOD SHINGLES ❑
such Improvements are not Intended or offered for safe.If,however,the bullding or Improvement
is veld within one year of completion,ihaowner-bullder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of vela.).
❑I,So owner of ro property,am exclusively contracting with licensed contractors to cerlstnlpl
the project(Sac.7004,Business we Profeta lam Code:The Conractor'e License Law does not PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for suM projects
.with a contractor(s)Ilcensed pursuant to the Contractor's Ucenm Law. PROVIDE MFGR. INSTALLATION SPECS.
F7 am exempt under Sec. ,B A P.C.for this rmeon
Owner Aare APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION -
I hereby efflrm unc er penalty of perjury one of the following declaration:
❑I have antl will mountain a CeriNdate of Consent to self-insure for Worker's Compensation, - BUIIdin ^
as provided for by Section 37M of the Labor code,for the performance of the work for which this y _b
permit leleeued. SBlsml rn
❑I hove eM will r maintain Workers f Mew work
Insurance,hthis m required by Section 3700 of
the Labor Cotle,for iha pedormenca of Ne work for which ih4 permit U beuso.My Workers Q� n1
Companea�u ^lmuraMe comer end Pohey number are: Total U,jb
Cerner
f�GL't'1 fi✓T /✓� I'* Pallor No 7-(57,0 f$�� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(Thio mefnn need not be completed H Ne permit is for one hundred dollars($1 DD)or lam.)
I centlty Met In the performance of the work br which this permit is Issued,I Melt not employ
any person In arty mu m er ao as to become Subject tot Workers'CompensaLam o
tion Lf Calk All roofs shall be inspected prior to any roofing material being
fomla. installed. If a roof is installed without first obtaining an
Date G Applicant ' • /r] inspection,I agree to remove all new materials for inspection.
NOTICE to A CANT: If,after making this Certificate of Exemption,you Should became AppIIC derstands and will comply with all non point
Subject to the Workers'Compensation previews of the Labor Cow,you moat forthmin comply
with such provisions or MIS permlt shall be deemed revoked. � sour regU tlOn S. -
I certify Met I have read this application and State that the above Informetlon Is correct.I agree
to comply with all city and county ordinances and state lawn relating to bullding construction.and A r f Verl sto be Cla or er.
hereby authorise repremnaOms of this clty to enter upon the above-mentioned property for In-
SpSctbn purposes. ////1(�� /' Qq
(We)agree to Save,Indemnify and keep harmless the City of Cupertino age=Ileellltles, .Y As `L" Lam' /'/
/ /
• lu monis,coals this permit. which may In hmY way accrue egsinat Sald Clry In consequence
of 1 e grenung of true perms. GNATURE OF APPLICANT D E
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