R-6601 PERMIT R_
APPLICATION FOR CITY of CUPERTiNO NUMBER 6 6 01
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
D0 IBD DAYS OF PERMIT ISSUANCE O
18D A
WIT DANS DAY LAST CALLED INSPECTION..
BUILDING ADDRESS
L RESIDENTIAL COMMERCIAL OTHER
OWNER'S fHAZARDOUS
YES ❑ n yes-I urwlerstartd that a Class A
NAME ��-�-/KP Z!�no1 to roof asserttdy is required.
- NO E] Irhbal I.C.B.O.P
ADDRESS -�OZGS� ,/`/n�w4 L�1 r EXISTING ROOF COVERING
PHONE Y00 - ZS�l�� NUMBER OF EXISTING COVERINGS
CONTRACTOR'S -
Co f:� TO BE REMOVED TO BE RETAINED
NAME of
ADDRESS �/� ��� /J_ ��/o �/ .��y TYPE OF ROOF COVERING
CrrvanP ///� o )�/T?7 /�' �� ;a' EXISTING
PHONE _ LPS? - � l4 / 3 BUILT-UP ROOFLICENSE
❑
NUMBER / f2-700
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em Ikanseci under poWskre of Chapter 9(commencing with Sedbn WOOD SHAKES ❑
]000)of Division 3 of the Business and professions Code,and my license m In fud force and
effecr.
q ❑
License Cue/ns :f—3 Lk.Number �Z ,70WOOD SHINGLES
Date `� -// �/ Contractor (�4f tf"+mf Z19OF11?6 OTHER(SPECIFY) ❑
OWNER41UILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Canbectols License Iaw for Ufa following reason.
(Sec.7031.5,Business shotProlessbrre Code: Arry city or countym
which requires a pedt to
construct,alter,Improve,demolish,or repair any stmcture,prlorto Its Issuance,also requires the BUILT-UP ROOF ❑
ePPlkant for each permlf to Ills a signed sletement that he ie licensed Pursuant o the Provisions
of the Contractors License Lew(Chapter 9(commencing with Section]000)of Mslon 3.
0l f e
Business and Prolemlons Code)or that he Is exempt merelrom and me bests r the e1 d ASPHALT SHINGLES
exemption.Any violation of Section]031.5 by any applicant far a per th and to
e dyll penalty of not more than eye hundred do9ene(5500).):
C]1, tyre property rmy ernpksyen with wages as ma neatkn,wiedo WOOD SHAKES ❑
ma work,antl the sirucNre Is Infende0 or otle r (Sec. ,Bu esa end Profae-
abns Cotle:The Contractor• nee law tloea rot to owner f property who builds or WOOD SHINGLES ❑
i mproves thereon,end who ee warkhlmseh or r h own employees,proAcetl that
such Improvemenfe ere no Mended or offer or eel If,fo Itre bulldin9 or Improvement
is sold within ane year of mpletlen,the owner Iber Il neve the burden of proving met he did OTHER (SPECIFY) ❑
not build or Improve for rpoae of sale)
1,mowner of Chep exr slvely acting Mm licensed connectors to construct
the Project(Sec.]Ona,Business ebsebru :The Conirecfale Lkenae Lew done net PROVIPC.B.2��ORT�{!f O.apply to en owner of property whoY s or Mproyos thereon,end wlo conbects for such projectsLL1Iwith a contractr(.)licensed pursu to the Coomactofs License law. PROVIFGR.INSTALLATION CS.
❑1 am exempt under Sac. ,B 8 P.C.for this reason
Owner Date APPLICATI DATE VALUAvFr0_N PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby Whom under penalty of perjury one of me foliowiig dexch n:
ee p❑1 have and r ded for by ll maintain a Section 3700 of me Labor Code,for the perrnficate of Consent to formanceofo�workefomr�I�chutne BY dJ Building 127,o,)
permit is Issued.
{��[1 neve and will maintain Workers Compensation Insurance,as required by Section 3700 0l Seismic
the Imo. bor Code,for me performance of me work for whoh mit this perIs issued.My Worker's 1�7,�J
'Compensation Insurance carrier and Policy num er are: Total
7"47-Ir' �4n0 Policy No..S//-//Z S�9� PERMIT AUTHORIZATION DATE
Carriers/
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE d fl N.Cf]
(This section need rot be compteteme permit Is for one hundred dollars(51 00)or lass.) Q>° /e-•Jtij�,w�,� O 9 .
I certgy that In the performance of me work for which this permit is issued.I shall not e=W
any person In any manner so as to become subject to the Workers'Compensation I-ews of Ca II- All roof^shall be inspected prior to any roofing material being
lornla. Installed. If a roof is installed without first obtaining an
Date C-�i g 9 Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If.after making this CentlfcMe of the Exampy� ,you should beeome Applicant understands and will comply with all non point
WNW to e Workers'Compenseflon provLaorm of the Inbar Code,yo moat Wthwim comply
with such provisions a this permit shelCbe deemed revoked. source regulations.
I certify that I have reed mis application entl state that the above Information I.correct.I agree
to comply wim all dry and county ordln rocd st
e.and! Pews relating to building construction,end All roof coverinnc la be class°C'or better.
hereby euthonza representatives of mis dry to enter upon Bre abwanontloned property for In- �— —�D �qr-,ys xk..VGC.r y
sp(We)onlon purposes. c
l� (We)agree to save,Indemnify entl keep h ny way me City of Cupaid G y Inagainstcon liabract il{ae, J/� ,/� 1 71
Jud me costs entl expenses wNch may In arty way accrue epelnst veld City In mnsaquence IGNA E OF APPLICANT DATE
of the grenWg of m®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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY