R-6690 PERMIT R- 6 6 9 0
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION, PERMITEXPIRATION
REROOF PERMIT (408)777-3228 _ PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• - 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
j0 3 C O szty' V4) RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA -
YES ❑ If yes—I understand that a Class A
NAME , rL.(/ - roof assembly is required.
_ t^ NO ❑ IrdLC.B.0.7
ADDRESS l��� ( --�--�,d EXISTING ROOF COVERING
PHONE - 0C NUMBER OF EXISTING COVERINGS
CONTRACTOR'S ,rte
W „ p L- Q ' TO BE REMOVED TOBE.RETAINED
NAME W +vww�.�
ADDRESS .y ' 4) 11- TYPE OF ROOF COVERING
CfrV 6 ZIP rT
/� EXISTING
PHONE 3C�(7 �� BUILT-UP ROOF �l
OCENSE ❑
NUMBER ASPHALT SHINGLES
DCENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provielons of Chapter 8(commencing with Secdon WOOD SHAKES ❑
7000)of DNWon 3 of the Business ark Professions Code,and my litems le In full force and
effect.
WOOD SHINGLES ❑
License CI Dc.Number
Date I — contractor o OTHER(SPECIFY) - ❑
ONBUILDER DECLARATION PROPOSED' -
hereby affirm that from em exempt from the Contractor's Ucerrse law for the Miming reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a Permit to
construct,after,Improve,demolish,or repair any structure, rfor to he leauance,also requires the UILT-UP ROOF D
applicant for such permit to file a signed statement that he P,licensed pursuant to the pr"slane
of the Contractors Ucen us Law((Chapter a(commencinga with Section 7000)of DlNsion 3 of the J U L 2 1999
Business and Professions Code)or that he is exempt Nerafrom ark the Castle for the staged SPHALT SHING
exemption.Any violation of Section 7031.5 by any applicant for a permit subject,the applicant to
a dvll penalty of not more than I"hundred dolare(55001.): D S KE$
C]1,as owner of the property,or my employe"with"asss their sole mmpeneatbn,will do - B ❑
the work,and the structure is not Intended or offered for sale(Sec.7041,Business and Profen- }f
slons Code:The Contrectorle Ucanae Law tloee not apply to an owner of property who Wllds or WOOD NG S
Improves thereon,entl who does such wom himself or through his own emplowea,provided that
such Improvement,are not Intended or offered for sale:If,however,the building or Improvement
Is sold within one year of completion,the owner-Wlitler will have the burden of proving that he dm OTHER(SPEC ) ❑
not build or Improve for purpose of sale.).
❑I,eso rof the property,am exciushrely contril with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew dove not PROVIDE I.C.B.O.REPORT NO.
app to an owner of property who Wilds or improves thereon,and who contract,for such projects
with a contractor,)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,8 8 P.C.for tha reason
Owner Dae
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under Penalty of perjury one G the fotlowlrp declaration: I
as pprrCAdedd for by will
3700 Certificate
f the�L tabor Code for ins performanic°er of heewon for whidlin Building r -���yy
permit haw anIssued. v ^'^ Seismic 0
' ❑I have entl will melnteln Workers Compensetlon Insurance,ss required q'Settlors 3]00 of (N
' the Labor Code,for the pa nce of the work for which this permit Is IsweedL My Workers^ )
comperma7_gr-erJ�e ra(rleg-;Polk��m re:POlicy No. LuW /�17 �V`T�v Total .I( ��
`Canler M'rIAJ (�•1/s*�C PERMITAUTHO ZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NC �'� ^
(Title section need not be conpletetl If the permit Is for one hundred dollars($ 0)a) Iless.) C ( Y
1 certlly Nat In the performance of the work for which this permit Is Issued,I ehall not employ
any person In any mama so ss to become a to the Workers'C en"Mon Law,of Call- All roofs shall be inspected prior to any roofing material being
fornla: installed. If a roof is Installed without first obtaining an
Data " Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: 8,after makingIde
ertiffcate of Exemption,you should became Applicant understands and will cora with all non point
subject to the workers'Compensation provla the Labor code,you moat forthwith coney pp comply p
with such pnodefons or this permit shall t serawicad. source regulations. .
I ceritly that l have read this ap llcaHon enthat the aboveInformation le correct.I agree �,(to comply with ell city and couny crdlnarkte laws relating to bulldingconavuNon,entl I roof covert to be class"y-JOr better.
hereby authorize representatives of this dry to enter upon the above-mentlwrod property for Ira
spectbn purposes. -
(Neff agree to sem,Indemnity and keep harmless the Clty of Cuperdrw ap Inst Ilabllltlee,
ju0pmenb,cote and expenses which may In arty way accrue against"toClry lb consequerpe S NATURE OF APPLICANT DATE
of IFe granting of this permlt -
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY