R-6340 APPLICATION FOR CITY OF CUPERTINO
NUMBER PERMrr
R� 6 3 4 .
REROOF PERMIT INSPECTION DIVISION PERMITEXPIRAnON
(4(?8)T77-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
IOc� RESIDENTIAL v
COMMERCIAL OTHER
OWNER'S. HAZARDOUS FIRE AREA
L� — YES ❑ If yes–I understand that a Class A
NAME W'T ' 1 L root assertlbly is required.
_ NO .>� inmal I.C.B.O.A -
ADDRESS �_ - EXISTING ROOF COVERING -
PHONE I I NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
NAME /T///111
c/_t j r)4vK\ 400 G �L"�V, TO BE REMOVED�_TO BE RETAINED
/
ADDRESS , f, (9 'V JOS C– r�5 TYPE OF ROOF COVERING
CITY 8 ZIP V /� 7"b
EXISTING
PHONE BUILT-UP ROOF
LICENSE
NUMBER 7 40 /5_� ASPHALT SHINGLES ✓❑
LICENSED CONTRACTORS DECLARATION -
hereby affirm that I am Business
under fessi mite of Chapter B(coma eis In with Seaton WOOD SHAKES ❑
]OOO)of DlNabn 3 cl Lha Buelneee entl Proleesbns Cade,entl my license le In full lane and
effect.
C � ? '7y S
3 WOOD SHINGLES �❑
License CloseLb.Number ��(
Data �' 2 9 Contractor �'t t yt CSA C OTHER(SPECIFY) j/y❑
OWNER-Me Conn DELLA License
PROPOSED !7'
hereby affirm that am exempt berm the e: Any dy or coup Lew for the following ap meson. /
(Sec.7031.5,after,lmip se entl Pmfesor II Cade: Airy dry or county whbh requires e permit to .
cautmct,orsu Improve,d file a signed elr mystructure,that
Is III o its issuance,rsi talso Merequiresn si me, BUILT-UP ROOF
at he Ct for such permit a fib a signed statement that h,lit licensed p 000)of tome pmAef the
of the Ca and Professions
Lew(Chapter a is WarnaMgg wtlh Section]000)s Dtv the 3 0l ins
• ex a ptio entl violation
iolatabn f Code)or that he a exempt applicant
entl the beets ler Ila alleged ❑
exemption.pan.Anof not o re Beclbn hundr by any s(S50 ).ler a permit eubjeca the eppilcent to 0
e dull penalty of not more than INe hundred!dollars(Ssoo)J:
I]1,as owner of the property,or my employees with wages as I sole compensation,will do OD"A S ❑
the work,ark the structure Is not Intended or offered for sale(Sac.7044,Business and Profee- q�
Code:The Cmtmctors Dcenae law does not apply to an owner of property who builds or 0117�Yyr LE�999 ❑
Twee merem,
and who Boas such work himself or mrou h his own employees,pprWi ed mat r
such Improvements are not Intended or offered triple.If,however,the bulking or=ovemera
is sold wlmin one year of complellon,the owner-builder will have the burden of proving that he dict HER(SPECIFY) 1:1not build or Inprpva for purpose of eels.).
❑I,as owner of the property,em exclusively,contracting with fkansed contractors to construct QQ
the projeec.7044,Business and Professions cto
Code:The Contrere Llceae laes w donot M O.
ap yct(Sto an ownerof property who WNtle or improves thereon,end whocontracts for such projects
with a conmactor(e)Ikensed pursuant to the Contractors License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under pmalty of perjury one of the following dedamtIm:
❑1 have and will maintain a Certhicate of Consent 10 saff4nsure for Workers Compensation, BUlldin
as provided for by Section 3700 of the Labor Cade,for the performance of me work ler which this
°a telesoe0' �� �� Seismic
Xhave entl will maintain Workers Compenaetlon Insurance,en required by Section 3]00 of
ih r Code,ler the performance of the work for which this permit is Issued.My Workers
Compensation Irreu�ra•Ync-e carder entl Policy number are: Total
CerrierS'Tr ,,,1) PoImyN�)/O60ZPERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O Q
(This section need not be completed 11 me permit is for me hundred dollars($100)or lees.)
I cerdly Chet In me performance of me work ler which this permit Is Issued,I shell net employ
any person In any manner so as to become subject to the WorI m;CompmscI Laws of call- All roofs shall be inspected prior to any roofing material being
1°cola. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
subject to the ork Ire CCoompentatbn pow onto of the Lafe of bor Code,you you sfwuk became Applicant understands and will comply with all non point
you must forthwith comply
with such proAekne or this parmn shall be deemed revoked. source regulations.
I cer0ty,that I have reed this application and state that the above Information is correct.i agree
to comply with all cry and county orcnemces and sate laws relating to Wikirg construction,and All roc coverings to lassb or better. -
specti Purpose repreeenathes of cols dry to enter upon me above-menibnetl property for In
heretknpurposes.
(We)agree to save,Indemnity an0 keep harmless the City of Cupenino against Ilebllldas,
Judgments,coed and expenses which Trey In any way amu t against said City consequence
of the granting of this permit. SIGNATURE OF APPLICANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
r
INSP. DATE INSP.—DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY /