R 3851 PERMIT
APPLICATION FOR CITY OF CUPERTINO I NUMBER R- 3851 I
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 W THIN 180 DAYS OF PERM T�SUANCE OR
180 DAYS FROM LAST CALLED INSPECTION
BUILDINGI^A'DDR/E�SS BUILDING USE
I / O(J RESIDENTIAL ,/ COMMERCIAL OTHER
OWNER'S _T
HAZARDOUS ROOF
NAME 1 /71/31
� A COVERING
EA CLASS
ADDRESS Q/9a3 +t �CGZc� � Lkt� EXISTING ROOF COVERING
PHONE V� — ( �`' NUMBER OF EXISTING COVERINGS
CONTRACTOR'S C (/n //� '
ITO BE REMOVED TO BE RETAINED
NAME
TYPE OF ROOF COVERING
ADDRESS `��C�•/� S4 Lx7�GC �LG(G(��L/��7GC�i/UG��I EXISTING
PHON � /Y/ O�IG� /1//f V /�� BUILT-UP ROOFS .
LICENSE 3C7 �3 ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION P (� I D
.anI With S affirm 7000)em licensed inch provisions of Cheater B Icommm' WOOD SHINGLES LV lJ
d with.mO i. 70001 OI Division 3 of the Business and roles m Co
and as cases is lul�fo p and effect .2
Lice Clm � •�fn LIc,Number �' 'q
Date // -F w• Contractor OTHER (SPECIFAPR 7 MET
1 OWNER-BUILDER DECLARATION L '
I hereby affirm that I am exempt from the Contractors License Law for PROPOSED CITY Uh (,UY
the following reason. (Sac. 7001.8, Business and Prolnsions Coda: Any city CIT f(IV
U
or county which requires a permit to construct, alter, improve,dem Olish,Or
repair any structure,prior to its issuance,also requires the spoil 101 such BUILT-UP ROOF
pomR to file•sinned statement that he a licensed pursuant to the provi onf
of the Contractor'.3 othe License Lew rofosseo s Ico Code)or that with SnHpt the(*7000)
fr m and 0 of arse Bfornth antl ged exe rn n. or that he Is exempt coon ASPHALT SHINGLES •Jam, �'Ll er�'7I'�
.
from and the basis for for spored exemption. Any ant to A of Section
]001.8 by any that ant fora.omit wblacb the applicant to•null penalty
of not more mat Ilve hundred property, r my employees WOOD SHAKES
❑ I, ti owner of the property.or he employees with wanes es r air sole
for ale (Sec. will do the work, and the rtruCwb a not intended Contractor's offered
for do ISec. 7044, Business antl PlobWOns who Tnsor imp over hereon. WOOD SHINGLES
Law who not Such to an owner of Property who builds or employees, pun thereon,
and woo tloy sucM1 work himself or through nn own employees,provitletl that
such Improvements are not intended OF offered for rile If, however, the OTHER (SPECIFY)
pullout Or improvement n sold within one year of completion, the owner
builder will have me burden of proving that he did not build or Improve for
Purpose OIAA..). PROVIDE I.C.B.O. REPORT NO.
❑ I, of owner of the PIOPOrlY, Am exclusively contracting with licensed
contractors to contract the protect (Sec. 7044, Business and Profession,
Code: The Contracmis License Low does not apply toan owner ofproperty pROVIDEMFGR. INSTALLATIONSPECS.
who build, or improves thereun,and who contract,for such Projects with e
contractor($)licensed pursuant to the Contractor's License Law.
❑n 1 am exempt under Sec. ,B&P.C.for this
na
APPLICATION DATE VALUATION PERMIT FEE
Owner Data ///777���'''777
WORKERS'COMPENSATION DECLARATION BUIIdI
1 hereby affirm that t have a certificate of consent t0 OI41nsubr o •car
380 sse of Workeri Comae tipn 11nsur,nce,or a certified yyang thereof IS... ,/l///1 G
Po10'�ev NO U.r Ca 5��00 (nU�CLl;ly ZCLA(�, `1 7 (� ��00 Seismic
om any
BCertified copy is hereby furnished. Total
Certified copy is tied x(ith the gitV im ¢iron gryuipn.
Applicant / L. [i
CERTIFICATE OF EXEMY'YION TftO'FI WOR KEYS' N.C. PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(Thu action need not be completed if the permit is for One hundred dol.
bas If100f or Ins.)
I certify sha that in me .any par.. of the work for which this permit p
toted, I shell not employ any Perron In mV mmner m ss to become subject
to the Workers'Compensation Lem of California
Data NT: Ifni /.
NOTICE should APPLICANT: o after making this nsati n Provisions of Exemption,
you rh od become st fort i the Work elf h such Compensation
provisi no 01 the S
Labor Ootla, you mutt forthwith comply with such Provisions o. this permit All rose shall be deemed revoked. Inspected prlOftO any roofing materiel being
I certify that I have read this application and state that the above informs. Installed. If a roof Is Installed without first obtaining an
bon is correct. I agree to comply with ell city and county ordinances and Inspection,18 gee t0 reR10Ve I new materlalBforina BC1IOn.
nab laws rebNng to building construction, d hereby authorize eprneT P g p
I.Hves of this city to enter upon the above-mentioned property for Inspection
(We)I agree to udg indemnify and expenses harmless Which the City of Cupertino 1 e
eau nst said City, contents,cum and expmbs wM1i is may In any wry accrue SIGNA URE OF APPLICANT
ewlnst aid City In conuouenro of me griming of inn permit DATE
JePRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE IINSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL'
INSP. DATE INSP. DATE IINSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
__ OFFICE COPY