R-3982 PERMIT
APPLICATION FOR
CITY OF CUPERTINO NUMB R R- 3982
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT PERMIT EXPIRES IF WORK IS NOT STARTED
(408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION
BUILDING ADDRESS - BUILDING USE
AP b S O MCY RESIDENTIAL COMMERCIAL OTHER
OWNER'S ROOF
NAME � � / ' n FIRE HAZARDOUS COVVERING
n AREA IWO CLASS
ADDRESS � EXISTING ROOF COVERING
PHONE / b Y' NUMBER OF EXISTING iOVERINGS 21
CONTRACTO
// TO BE REMOVED -40 TO BE RETAINED
NAME TYPE OF ROOF COVERING
CI
TDYR&ZIP //0 �O /J v 51 J EXISTING
PHONF(3—/0) 3_5Z -,,2L 73 7 _ BUILT-UP ROOF /
LICENSE `��/ ASPHALTS GLES ( 5
NUMBER d yV00D$ KE$
Lm ENSED CONTRACTORS under DECLARATION
I hereby affirm that I of ni.1cm under a Bunions of Chapter e s ons Code
cloy wins Section 7000) r Drvi,lon a of me eusmeu she Professions coda, WOOD ISLES
and my Cis 1 In c ffact /!a�d
License a:g L ."Sfgr`a Lm.Number �— OTHER (SP IFY') C
Data /3J7 Y S Contractor Y
OWNER-BUILDER DECLARATION '
I hereby affirm that I am exempt from the Contractor's License Law for PROPOSED
the following reason. (Sac. 7031.5, Business and Professions Code: Any City
01 county which requires a permit to construct, alter, improve, demoluh,or
repair anv structure,prior tom issuance also .our,"ma applicant for Such BUILT
ROOF
permit to tlla a signed statement that he is licensed pursuant to the previsions
of th a Contractor', License Law (Chapter 9 (commencing with Sacbon 7000)
of Division 0 of the Business and Professions code)or that he Is exempt them ASPHALT SHINGLES
from and the basis for the alleged exemption Any violation of Section
7001 5 by any applicant for a permit ublecb the applicant to a civil penalty
of not more met five hundred dollars($500). ). WOOD SHAKES A
❑ I, as owner of the property, or my employee+with wages as men sole �r
compensation,will do the work, and the structure Is not intended or offered WOOD SH INtyJa�S
for sole (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to on owner of property who builds or Improves thereon, VX 19gS
and who does such work himself or through his own employees,provided that /tr
such improvements are not intended or offered for sale. If, however, the OTHER (SPECIFY)
building or improvement is sold within one year of completion, 100 owner Jr'
builder will have the burden of proving that he did not build or Improve for LUhtty
Purpose of sale) PROVIDE LC.B.O. REPd RrfJNO.
❑ I, as o of the property.am exclusively contracting with licensed
convectors to construct the protect (Sac 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves thereun, and who contracts for such protects Wpm a
conVector(O It ensed pursuant to the Contractors License Law.
❑ I em exempt under Sec. or C for this
reason APPLICATION DATE VALUATION PERMIT F
Owner Tau (O
WORKERS'COMPENSATION DECLARATION Building
I hereby etbrm that I have certificate of consent to self insure,or ace,
•� / �T'')�
nflceu of Workari Compaps^ln Insurance artilud copy sof(Sec T�7r0 - +/ V
aeoo,L.b. Seismic
Policy No. C pent �^ 1
caruNad.0ov is hereby furnished. - Total
Cartih.d coPV is filed with the city Inspection division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.0 PERMIT AUTHORIZATION DATE
COMPENSATION I N S URANCE
(This action head not be completed d the permit Is for one hundred dot
Pars($100)or Ins.)
I certify that in the
lo performance person of the work for .11. this permit n / //�I
issued, 1 {hall not employ any parson In any manner sa a+tp become+UblaCt
tot Workeri Compensotion Laws of bhlornn
Date Applicant _ J
NOTICE TO APPLICANT If, after making thrs CoimficaM of Exemption,
You should become Subject to the Worker{' Compensation provisions of the
Labor Coda,you must forthwith comply with such provisions or this permit
shall be cleansed revoked. All roots shell be inspected prior to any roofing material being
I certify mat I nave read this application and state that the above informs installed If a roof is installed without first obtaining an
front
Is correct. 1 .grea to comply with all city and county ordinances and inspectio I agree to rem ve all new meterialsforinspection
Rate laws elating to budding construction, and hereby authorize reprosem
[etivas) mla cloy to enter Upon the above m harmless property for Inspection
purpose,.
(We) great liabilities, Bees in ts.cos s end keep es which the Coy of ay acc ue
against aid ity i cons a consequence cons the expanses which may in my way accrue and
aealmt cam Ciry in caneaquanca of me granting of ion permit S NATUFjE OF APPLICANT
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL,
INSP. DATE INSP. DATE INSP. DATF
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY