R-6286 APPLICATION FOR CITY of cuPERTwo
NUMBER PERMIT
Ff-, 6 2 8 6
INSPECTION DIVISION - P RMITEXPIRATION
REROOF PERMIT (408) 7T7-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS .
,r1 �
RESIDENTIAL—" COMMERCIAL OTHER
OWNERSHAZARDOUS FIRE AREA
YES ❑ II yes—I understand that a Class A
NAME roof assembly is required.
�X NO- ❑ InAlal I.C.B.O.R
xal,�.lr7 � ✓�� C..�-� EXISTING ROOF COVERING
ADDRESS `
PHONE NUMBER OF EXISTING COVERINGS /
CONTRAC R'S r"—
TO B R OJED _: BYO. E RETAINED
NAME � _
VER N
CITY 8 ZIP 7 J �' 11SPP_HA—_,LT_-_9HINGr-ES-2
ov 19 19
PHONE y�� -`t'�LICENSE •'�-7 97 - LT-UP ROOF ❑
NUMBER d ; ❑
' LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ��,
. .000)of Division 3 of the Business and Professions Code,and my license
le In lull force end ,
enact
' WOOD SHINGLES* El
Ucense Claes Lk.Number / dd
/rf'3'4 OTHER(SPECIFY)
Date Convector
OWNER-McConDER OtorsUcTI PROPOSED �/
hereby el Bu n that I em exempt from Me e: A,cry Uconee Lew for the Mies,a reason. G
(Sao.]0315,r,Imprse and Pro oasis Cade: Airy dry or oaunry Issue re,else a pared e
construct,after,su,Improve,tl odea , nedstirem endure,prior tolls Issuance,elserequirespro0sthe BUILT-UP ROOF
of the a for each Uce to Elle a signed statement that he Ish Section
pursuant to the provisions
of the Contractors U Professions
Lew Chapter a(commencingg with Sectlon.he b of for to 3 0l the
• Business and Ylolatabn f Cone or Met he b exempt to tfor a arm the beefs for the alleged ASPHALT SHINGLES —
acimll"n.Any fhotmnofSection nWeh0ndr bosrryapplicantfora permit augecro the applicant to
e dull penally of rwt more Ihan Me hundred tldlere($500).):
C]1.es owner of the Property,or my employees with wages as their sale compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(See.7044,Business and Pefes-
slons Cade:The Contractor's Ucenea law does hot apply to an owner of properly who builds or WOODs thSHINGLES ❑
Improveereon,entl who does such work himself or through his own employees,provided that
such Improvement,are not Intended or offered lar sale.If,however,the building or Improvement
Is sold whhln one year of completion,the owner-bulloer wal have Ne burden of proving that he did OTHER(SPECIFY) ❑
apt bulel or kn ecve for purpose o sale.).
❑I,as weer of the property,em exclusNely confined inp with licensed cantren to construct '
the project(Sao.70".Business and Professions Code:The Contractors ace f.'ew-3aee not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or lmproae thereon,and who contra for such prWects
with a contractags)licensed pursuant to the Contractors Lksnee Lew. o PROVIDE MFGR.INSTALLATION SPECS.
1 em exempt under Sec. ,B 8 P.C.for M4.r-kson
Owner Date
W'ORKER'S COMPENSATION DECLARATION ' ' APPLICATION DATE VALUATION PERMIT FEE
I hereby alllrm under penally of perjury one of the following declaration: �I
❑I lave and wIH maintain a Certificate of Consent to solf4 sure for Workers Compensation, `_CWjr Building
as prodded for by Sootion 3.00 of the Labor Code,for me performance of Us work for which We d\—JC'_"'�J
permit Is lesuel. Seismic 7�
-11 have and will maintain Workers Campera atlon Insurance,a,required by Section 3700 of
the Labor Code,for the performance of the work for which this permit Is issued.My Worker, / ' '
Compens aNnsuonce carrier and Iky number are: '✓ Total 1111716 '
�
Carder Policy No. w�% `77 PERMIT AUTHORIZATION DATE
`- CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE IN C,[_]
(Thin section need not be completed If the permit Is for one hundred dollars($1 DO)or lees.).
any p rson In any mannerr so ee o rforri of the wdr,for become Subject to the Wh thisorkers Comermit I, pensation Lawel s employ alik All roofs shall be inspected prior to any roofing material being
fomle. installed. If a roof is installed without first obtaining an
Date Applicant - inspection,I agree to remove all new materials for inspection.
NOTICE e APPLICANT:MoCCompennallon prodaloo,ofWe theLate abor Code,you you ahoalo become
omply Applicant understands and will comply with all non point
subject to pro inions r you must forthwith comply
with each provisions or ihle pemnh shell be deemed rarokee. SOUfCe rBJUIatIORS. '
I cart that l have read this application and state that Me above Information is carrect i agree '
to comply with all dry and county ardinuadis ark state hews relating to building construction,and All^rrp�o`ff coverings to be class Q5 or better.
herebyn purposes.
lze representatives of this dry to enter upon the above-mentknetl property for In-specto (A iC/✓ ` ` �!' L' mw
'u her"n authorize
r
(We)agree to save,Indemnify ark keep harmless Me Cry of Cupertino agslno IladlNes, l
ludaments,conte ane expenses whin may In ary way accrue against saki Gty In coneequerKp SIGNATURE OF APPLICANT DATE
• of i e granting of N:,parmll.
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